Cardiac Injury and Severe Outcome in Children and Adolescents with COVID-19

Background: Cardiac injury associated with multi-system inflammatory syndrome in children (MIS-C) has been extensively reported but the impact of cardiac injury in children with SARS-CoV-2 infection in the absence of MIS-C has not been well described. In this study we describe the cardiac involvement found in children with positive SARS-CoV-2 PCR tests and evaluate the association of cardiac injury with severe outcome in this population.

Methods: A retrospective chart review of all patients ages 0-21 presenting to the emergency department or admitted at our institution during and just beyond the peak of the COVID-19 pandemic at our institution was performed. We excluded patients with MIS-C, cardiomyopathy, or complex congenital heart disease. Cardiac injury was defined as elevated high sensitivity troponin and/or N-terminal pro-brain type natriuretic peptide above 99th percentile. Severe illness was defined as need for advanced respiratory support (positive pressure or mechanical ventilation above baseline), inotropic or vasopressor support, and/or death from any cause during admission.

Results: During the study period there were 103 patients with positive SARS-CoV-2 PCR, 17 of whom were excluded for MIS-C, 4 of whom were excluded for cardiomyopathy, 2 for complex congenital heart disease including one with repaired Taussig-Bing anomaly and one with double outlet right ventricle who underwent Fontan surgery. Of the 80/103 (78%) patients remaining in the analysis, 31/80 (39%) were female and the median age was 12.5 years (IWR 1.9-17.5). High-sensitivity troponin T and/or NT-proBNP were measured in 27/80 (34%) patients and abnormalities were present in 5/27 (19%), all of whom had underlying comorbidities such as lung disease, diabetes, or genetic syndromes. Severe outcome occurred in 14/27 (52%) patients and 5/5 (100%) of those with cardiac injury as compared to 9/22 (41%) patients without cardiac injury (p < 0.05). Advanced respiratory support was more common in those with cardiac injury as compared to those without, occurring in 5/5 (100%) patients with cardiac injury and in 8/22 (36%) patients without cardiac injury (p < 0.05). Electrocardiographic abnormalities were identified in 14/38 (37%) studies and no left ventricular dysfunction was identified on echocardiography.

Conclusion: During the initial peak of the pandemic at our institution, cardiac injury was present in 19% of those for whom high-sensitivity troponin and/or NT-proBNP were measured. Presence of cardiac injury was associated with greater risk of severe outcomes including advanced respiratory support. Larger studies to determine the true incidence of cardiac injury in children with COVID-19 would be useful to guide recommendations for standard workup and management.