Signs of Cardiac Injury in Critically Ill Paediatric Patients with COVID-19: a Single-Center Experience in Brazil

To detect myocardial injury in critically ill paediatric patients, and to compare cardiac involvement between children with severe acute respiratory syndrome (SARS) and children with multisystemic inflammatory syndrome (MIS-C).

Methods

All COVID-19 children admitted to a referral intensive care unit were prospectively enrolled and had a two-dimensional echocardiogram (2D-TTE) and a cardiac troponin I (cTnI) assay within the first 72 hours. For statistical analysis, two-sided p < 0.05 was considered significant.

Results

Thirty-three patients were included, of which 51.5% presented elevated cTnI and/or abnormal 2D-TTE and 36.4% needed cardiovascular support, which was more frequent in patients with both raised cTnI and 2D-TTE abnormalities than in patients with normal exams (83.3% and 33.3%, respectively; p 0.006, 95% CI = 0.15-0.73). The most common 2D-TTE findings were pericardial effusion (15.2%) and mitral/tricuspid regurgitation (15.2%). Signs of cardiac involvement were more common in MIS-C than in SARS. MIS-C patients also presented a higher rate of the need for cardiovascular support (66.7% vs 25%, p 0.03, 95% CI = -0.7 to -0.04) and a more frequent rate of raised cTnI (77.8% vs 20.8%; p 0.002, 95% CI = 0.19 to 0.79). The negative predictive values of cTnI for the detection of 2D-TTE abnormalities were 100% for MIS-C patients and 73.7% for SARS patients.

Conclusion

signs of cardiac injury were common, mainly in MIS-C patients. 2D-TTE abnormalities were subtle. To perform a cTnI assay upon admission might help providers to discriminate those patients with a more urgent need for a 2D-TTE.

COVID-19; Heart; Child

Characteristics	All patients (33)	SARS (24)	MIS-C (9)	p	95% CI
Male	19 (57.6%)	15 (62.5%)	4 (44.4%)	0.35
Age (years)	6.4 ± 5.6	5.7 ± 5.6	8.2 ± 5.5	0.2
BMI (Kg/m2)	18.2 ± 6	17.9 ± 5.8	18.9 ± 6.7	0.79
Chronic disorders	18 (54.5%)	16 (66.7%)	2 (22.2%)	0.02	0.06 to 0.69
Haematologic	6 (18.2%)	6 (25%)	0
Cardiac	3 (9.1%)	2 (8.3%)	1 (11.1%)
Neurologic	3 (9.1%)	2 (8.3%)	0
Obesity	3 (9.1%)	2 (8.3%)	1 (11.1%)
Nephrologic	2 (6.1%)	2 (8.3%)	0
Pulmonary	2 (6.1%)	2 (8.3%)	0
Diabetes	1 (3%)	1 (4.2%)	0
Length of ICU stay (days)	6 (3-12)	7 (3-12)	5 (3-7)	0.32
Length of hospital stay (days)	14 (10-19)	15.5 (12-21.2)	10 (7-14)	0.09
Respiratory support	27 (81.8%)	22 (91.7%)	5 (55.6%)	0.008	0.05 to 0.67
Oxygen Only	14 (42.4%)	13 (54.2%)	1 (11.1%)
CPAP	1 (3%)	1 (4.2%)	0
Mechanical ventilation	12 (36.4%)	8 (33.3%)	4 (44.4%)
Duration of respiratory support (days)	5 (1-9)	6(2.5-10.5)	2 (0-5)	0.14

Characteristics	All patients (33)	SARS (24)	MIS-C (9)	p	95% CI
Cardiovascular support	12 (36.4%)	6 (24%)	6 (66.7%)	0.03	-0.69 to -0.04
Maximum VIS *	19 ± 17	11 ± 6	28 ± 21	0.051	-37.6 to 2.6
Abnormal cTnI	12 (36.4%)	5 (20.8%)	7 (77.8%)	0.002	-0.79 to -0.19
Peak cTnI		0.41 ± 0.48	0.61 ± 0.61	0.56
Abnormal Echo and cTnI		1/5 (20%)	4/7 (57.1%)	0.2
High pro-BNP	22/25 (88%)	15/17 (88.2%)	7/8 (87.5%)	0.96
High CKMB	10/19 (52.6%)	5/11 (45.4%)	5/8 (62.5%)	0.46
Abnormal 2D-TTE	8 (24.2%)	4 (16%)	4 (44.4%)	0.08
LV systolic dysfunction	2 (6.1%)	0	2 (22.2%)	0.1
RV systolic dysfunction	1 (3%)	1 (4.2%)	0	0.28
TR/MR	5 (15.2%)	2 (8.3%)	3 (33.3%)	0.47
Pericardial effusion	5 (15.2%)	4 (16.7%)	1 (11.1%)	0.03	0.04 to 0.96
WMA	1 (3%)	0	1 (11.1%)	0.28
Coronary abnormality	0	0	0
MLCA Z-score	-0.23 ± 0.8	-0.23 ± 0.88	-0.23 ± 0.57	1
RCA Z-score	0.16 ± 0.87	0.14 ± 0.88	0.22 ± 0.9	0.81

Patient number	1	2	3	4	5	6	7	8	9	10
Gender	M	M	M	F	F	F	M	F	F	F
Age	14 y	12 y	7 y	13 y	3 y	11 y	20 m	10 m	2 y	13 y
BSA	1.21	1.39	1.02	1.55	0.54	1.15	0.58	0.41	0.35	1.58
BMI	13.1	17.2	17.7	22.6	12.3	15.5	14.7	16.7	16.6	17.7
Comorbidity	SCD	-	CHD	-	BMA	-	-	-	CPD and CP	Diabetes
Presentation	SARS	MIS-C	SARS	MIS-C	SARS	MIS-C	MIS-C	SARS	SARS	SARS
Length of ICU stay W(days)	12	5	22	7	8	6	3	2	12	5
Length of hospital stay (days)	16	10	34	9	8	10	7	15	18	8
Respiratory support (days)	4	5	10	2	8	3	0	2	17	5
Mechanical ventilation (days)	0	3	2	0	1	2	0	0	0	2
Peak cTnI (cut-off 0.1 ng/ml)	< 0.1	0.27	< 0.1	1.91	< 0.1	0.58	0.22	0.13	< 0.1	< 0.1
cTnI normalization	-	3 days	-	4 days	-	5 days	1 day	1 day	-	-
Maximum VIS	0	50	5	15	10	55	10	0	10	0
Pro-BNP (cut-off 125 pg/ml)	NA	27183	5546	5341	988	22985	31188	1133	2445	NA
CKMB (cut-off 25 ng/ml)	NA	19.4	17.9	28.4	NA	41	23.6	24.4	NA	NA
Initial TTE	Minimum PE	Mild MR	Severe RV dysfunction, mild/moderate LV dysfunction, severe TR	Mild LV dysfunction, wall motion abnormality, mild PE	Mild PE	Moderate MR, mild LV dysfunction	Mild TR	Moderate PE	Mild PE	Mild MR
Discharge TTE	NA	normal	Severe RV dysfunction, mild LV dysfunction, moderate TR	Normal	Mild PE		Mild TR	Mild MR, minimum PE	NA	NA

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