Coronary Artery Dilation in Pediatric Patients with Asymptomatic or Mild COVID-19 Infection

Background: COVID-19 infection and Multisystem Inflammatory Syndrome in Children (MIS-C) in hospitalized pediatric patients have been associated with cardiac manifestations . Generally, children have asymptomatic or mild COVID-19 infection and MIS-C is rare. We examined the cardiac implications of asymptomatic or mild COVID-19 infection in non-hospitalized children to better define this outcome.

Methods: We queried the electronic medical record for patients ≤18 years-old referred for outpatient pediatric cardiology evaluation following COVID-19 infection from 5/1/2020 - 4/30/2021. We excluded patients without a confirmatory COVID test (PCR or serology), who had been hospitalized for any condition related to COVID-19 (including MIS-C), or with history of cardiac disease that could affect coronary artery dimension. We recorded electrocardiogram (EKG) and echocardiogram (ECHO) findings, and laboratory studies performed during a preceding emergency department or most recent cardiology clinic visit.

Results: Of 277 records reviewed, 134 met inclusion criteria (Figure 1); mean age 9.6 +/- 5.4 years, 53% male. 131 patients had a normal or minor variant on EKG and ECHO (Table 1). Three patients had coronary artery (CA) abnormalities on ECHO:
1) 7-year-old male with history of mild COVID-19 infection; borderline left main CA dilation (Z-score +2.1 on largest measurement). Plan for close follow-up and repeat ECHO.
2) 16-year-old male with positive COVID serology; dilated right CA (Z-score +2.3); started on aspirin. Plan for close follow-up, repeat ECHO, and possible CT angiography.
3) 8-year-old male with history of mild COVID-19 infection; dilated left main CA (Z-score +2.6); started on aspirin; CT angiography confirmed enlarged left main CA. Plan for close follow-up and repeat ECHO. Prior to COVID-19 this patient had an ECHO with normal CA dimensions (Z-score -0.4).

Conclusion: While cardiac disease in children with COVID-19 infection is uncommon, we report three pediatric patients who may have developed CA dilation following confirmed mild or asymptomatic COVID-19 infection. Current return to play guidelines recommend cardiology evaluation after moderate to severe COVID-19 infection, as studies have reported myocarditis in young healthy athletes. Our study adds to the body of literature on COVID-related cardiac disease and may have important implications for post-COVID surveillance in young healthy children following minimal illness. Data collection is ongoing