Published online Nov 6, 2020. doi: 10.12998/wjcc.v8.i21.5250
Peer-review started: September 1, 2020
First decision: September 13, 2020
Revised: September 16, 2020
Accepted: October 13, 2020
Article in press: October 13, 2020
Published online: November 6, 2020
Since the beginning of the pandemic, coronavirus disease-2019 (COVID-19) in children has shown milder cases and a better prognosis than adults. Cardiovascular involvement is emerging as one of the most significant and life-threatening complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in adults.
To investigate if cardiovascular involvement could be a significant risk factor for severe COVID-19 in children.
We aimed to summarize the current knowledge about the potential cardiovascular involvement in pediatric COVID-19, in order to give a perspective on how to take care of them during the current pandemic emergency.
A literature search to identify publications from January 1st, 2020 until July 31st, 2020. was conducted using PubMed and MEDLINE. Also, the websites of the health organizations including World Health Organization and Centers for Disease Control and Prevention and the website of the Johns Hopkins Coronavirus Resource Center were reviewed to provide up to date numbers and infection control recommendations. The included studies were categorized by whether the study involved previously healthy patients or patients with pre-existing cardiac conditions. For pediatric multisystemic inflammatory syndrome (PMIS) temporally associated with COVID-19, multiple meta-analyses were conducted to summarize the pooled mean proportion of different cardiovascular variables in this population in pseudo-cohorts of observed patients. All the statistical analyses were performed using the STATA 14.0 (StataCorp. College Station, TX, United States).
We included a total of 193 articles in this review. The most relevant articles were 16 studies with size > 10 patients and with complete data about cardiovascular involvement in children with PMIS, 10 articles reporting sporadic cases of myocarditis, pulmonary hypertension and cardiac arrythmias in previously healthy children, and another 10 studies reporting patients with pre-existing heart diseases. The meta-analysis of 16 studies with size > 10 patients and with complete data about cardiovascular involvement in children with PMIS showed that PMIS affects mostly previously healthy school-aged children and adolescents presenting with Kawasaki disease-like features and multiple organ failure with a focus on the heart, accounting for most cases of pediatric COVID-19 mortality. Out of PMIS cases we identified 10 articles reporting sporadic cases of myocarditis, pulmonary hypertension and cardiac arrythmias in previously healthy children. We also found another 10 studies reporting patients with pre-existing heart diseases. Most cases consisted in children with severe COVID-19 infection with full recovery after intensive care support, but cases of death were also identified. There is an increasing concern about the delay of the diagnosis and adequate management of congenital heart diseases (CHD) complications and a delay of the optimal timings for corrections of some stable CHD due to the pandemic, with a potential direct effect on morbidity and mortality.
There is still scarce data about the role of cardiovascular involvement in COVID-19 in children. Based on our review, all children (previously healthy or with pre-existing heart disease) with acute COVID-19 requiring hospital admission should undergo a cardiac workup and close cardiovascular monitoring to identify and treat timely life-threatening cardiac complications. The management of the different cardiac conditions should be based on the correspondent clinical guidelines, expert panel recommendations and physician´s experience.
Although cardiovascular involvement seems to be a crucial risk factor associated with severe pediatric SARS-CoV-2 infection, more evidence in the form of multicenter collaborative studies is necessary to elucidate this association.