key: cord-0779766-l5em0fed
authors: Khanna, Sudhansoo
title: The 3C’s: COVID-19, Children, and Cardiac Surgery - Do we know enough?
date: 2020
journal: Braz J Cardiovasc Surg
DOI: 10.21470/1678-9741-2020-0255
sha: 37b4f9d56caeea3e3da4755577c0cd397b534b20
doc_id: 779766
cord_uid: l5em0fed

nan

to frequent viral infections in childhood may seem protective. Third, a higher constitutional lymphocyte count in children is proposed as a protection mechanism against SARS-CoV-2 [6] . However, the actual reason may continue to be a mystery due to the smaller number of immunological studies available to date due to the smaller number of infected patients in the pediatric population.

CoVs are known to affect the cardiovascular system. However, there are significant gaps in our current understanding of the pathophysiology and effects of COVID-19, especially on the cardiovascular system. Although several mechanisms have been proposed, such as eliciting a 'cytotoxic storm' , systemic inflammatory response syndrome (SIRS), plaque instability and even cases of direct cytotoxic effects on myocardium (myocarditis) have been reported, SIRS appears to be the most important mechanism [7] . Cardiopulmonary bypass (CPB) is an integral component of most corrective cardiac surgeries. CPB is known to produce SIRS, which can cause myocardial and pulmonary dysfunction in the postoperative period [8] . Therefore, it is easily comprehensible that a nosocomial SARS-CoV-2 infection postoperatively after cardiac surgery under CPB can be potentially lethal due to the compound impact of inflammatory response by both CPB and SARS-CoV-2.

SARS-CoV-2 has a unique marked affinity towards host ACE2 receptor. ACE2 receptor-dependent entry of SARS-CoV-2 has put forward a therapeutic dilemma. On the one hand, ACE inhibitors (ACEIs) or angiotensin receptor blockers (ARBs) can increase the viral entry into host cells by compensatory up-regulating ACE2 receptors, thus making the individuals on these drugs more susceptible to SARS-CoV-2. On the other hand, compensatory up-regulation of these ACE2 receptors may provide a protective effect against inflammatory response of SARS-CoV-2 [7] . Currently, we have no conclusive evidence regarding the discontinuation of ACEIs/ARBs in a case of COVID-19 [9] .

Several trials are underway in our pursuit to find a vaccine or therapeutic drug against SARS-CoV-2. Anti-malarials, like hydroxychloroquine and a couple of anti-viral drugs, have been proposed, but their efficacy is doubtful to say the least. We face this critical issue of conducting cardiac surgery under CPB in children in this era of COVID-19. Until we obtain conclusive data regarding the management of pediatric cardiac patients with COVID-19, we must rely on our clinical judgment.

currently have no prophylactic vaccine or definitive curative treatment against SARS-CoV-2.

CoVs seem to have mastered the art of deception, in the way it evolves every few years to cross the species barrier, resulting into epidemics or a pandemic every 10 years for the past 3 decades. The global catastrophe created by another member of the CoV family, which was previously thought to be quite benign, has posed serious questions regarding our preparedness to deal with this ever-evolving set of zoonotic diseases. We must solve this mystery surrounding CoVs so that history may not repeat itself once again in the future.

Although COVID-19 emerged as an acute infectious pandemic, it could soon evolve into a chronic epidemic similar to influenza due to genetic recombination. Thus, we will repeatedly

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