key: cord-0809698-f2pm3sbf
authors: Seidel, Franziska; Kuehne, Titus; Kelle, Sebastian; Doeblin, Patrick; Zieschang, Victoria; Tschoepe, Carsten; Al‐Wakeel‐Marquard, Nadya; Nordmeyer, Sarah
title: Cardiovascular magnetic resonance findings in non‐hospitalized paediatric patients after recovery from COVID‐19
date: 2021-10-27
journal: ESC Heart Fail
DOI: 10.1002/ehf2.13678
sha: c72f59d800468980226f839f3440fd2800b8a0de
doc_id: 809698
cord_uid: f2pm3sbf

AIMS: Our study aimed to investigate the cardiac involvement with sensitive tissue characterization in non‐hospitalized children with coronavirus disease 2019 (COVID‐19) infection using cardiovascular magnetic resonance (CMR) imaging. METHODS AND RESULTS: We prospectively enrolled children who recovered from mildly symptomatic COVID‐19 infection between November 2020 and January 2021. Patients underwent CMR at 1.5 T (Achieva, Philips Healthcare, Best, the Netherlands) including cine images, native T1 and T2 mapping. Healthy children and paediatric patients with biopsy‐proven myocarditis served as control groups. We performed CMR in 18 children with a median (25th–75th percentile) age of 12 (10–15) years, 38 (24–47) days after positive PCR test, and compared them with 7 healthy controls [15 (10–19) years] and 9 patients with myocarditis [10 (4–16) years]. The COVID‐19 patients reported no cardiac symptoms. None of the COVID‐19 patients showed CMR findings consistent with a myocarditis. Three patients (17%) from the COVID‐19 cohort presented with minimal pericardial effusion. CMR parameters of COVID‐19 patients, including volumetric and strain values as well as T1 and T2 times, were not significantly different from healthy controls, but from myocarditis patients. These had significantly reduced left ventricular (LV) ejection fraction (P = 0.035), LV global longitudinal strain, and left atrial strain values as well as elevated native T1 values compared with COVID‐19 patients (P < 0.001, respectively). CONCLUSIONS: There was no evidence of myocardial inflammation, fibrosis, or functional cardiac impairment in the studied cohort of children recently. CMR findings were comparable with those of healthy controls. Pericardial effusion suggests a mild pericarditis in a small subgroup. This is pointing to a minor clinical relevance of myocardial involvement in children after mildly symptomatic COVID‐19 infections.

The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has led to the global pandemic of coronavirus disease 2019 . Recent cardiovascular magnetic resonance (CMR) studies have reported frequent cardiac injury in adults with COVID-19 infections. [1] [2] [3] Data in paediatric patients are limited and mainly related to the occurrence of multisystem inflammatory syndrome in children associated with SARS-CoV-2 infection (MISc), which presents mostly with a severe onset. [4] [5] [6] [7] The prevalence and clinical role of cardiac injury in paediatric COVID-19 patients without systemic inflammation is not well studied using sensitive methods for myocardial tissue characteriza- tion. One study on thoracic imaging reports a myocarditis in only one of 91 children with COVID-19 infections. 8

Our study aimed to investigate the presence of cardiac involvement including functional impairment, myocardial inflammation, and fibrosis using CMR without contrast-enhancement and sensitive CMR methods for myocardial tissue characterization in non-hospitalized children with COVID-19.

We prospectively enrolled children who recovered from mildly symptomatic COVID-19 infection between November 2020 and January 2021. All infections were diagnosed by positive polymerase chain reaction (PCR In addition, children who underwent cardiomyopathy screening due to a family history of cardiomyopathy, but without any pathologies and pathogenic cardiomyopathy variants were included as controls. 9 Paediatric patients with biopsy and CMR proven myocarditis enrolled within the MYKKE Registry served as a reference with myocardial inflammation. 10 Parents or legal guardians gave written informed consent. Ethical approval was obtained from the responsible ethics committee.

We performed CMR in 18 children recovered from COVID-19 infection with a median (25th-75th percentile) age of 12 (10-15) years, 38 (24-47) days after positive PCR test, and compared them with 7 healthy controls [15 (10-19) years] and 9 patients with myocarditis [10 (4-16) years]. CMR was performed significantly earlier after symptom onset in the myocarditis group compared with COVID-19 patients (P = 0.013, Table 1 ). Demographics and CMR parameters are presented in Table 1 . The COVID-19 patients reported mild symptoms including fatigue (61%), fever (56%), respiratory symptoms (50%), loss of smell and taste (44%), gastrointestinal symptoms (39%), and dyspnoea (17%).

None of the COVID-19 patients showed CMR findings consistent with a myocarditis based on the updated Lake Louise Criteria. Findings of a 12-year-old female COVID-19 patient are displayed in Figure 1 . Three patients (17%) from the COVID-19 cohort presented with minimal pericardial effusion. CMR parameters of COVID-19 patients, including volumetric and strain values as well as T1 and T2 times, were not significantly different from healthy controls. In contrast, myocarditis patients more often showed pericardial effusion (67% vs. 17%; P = 0.026) and wall motion abnormalities (P < 0.001) and had significantly reduced left ventricular (LV) ejection fraction (P = 0.035), LV GLS, and left atrial strain as well as elevated native T1 values compared with COVID-19 patients (P < 0.001, respectively; Table 1 ). See Figure 2 as an overview of different CMR findings between healthy controls, the COVID-19, and the myocarditis cohort.

In the studied cohort of children, recently recovered from mildly symptomatic COVID-19 infections, no evidence of myocardial inflammation, fibrosis, or functional cardiac impairment was found. CMR findings were comparable with those of healthy controls but clearly different to findings in myocarditis patients. With a longer time difference between symptom onset and CMR in COVID-19 patients, a cardiac involvement in the first 4 weeks cannot be ruled out. Especially myocardial oedema might have not been detected in our study more than 1 month after symptom onset. 3 In children, the cardiac involvement after mild COVID-19 infections was lower compared with studies in adults with mild or moderate COVID-19 infections, where high frequencies of CMR manifestations (30-78%) as ongoing myocardial inflammation, positive late gadolinium enhancement, and LV dysfunction were reported. 1, 2 The minimal pericardial effusion might be a sign of mild pericarditis in this paediatric cohort, which could also be detected in adults studies in wide range of 0-58% within 10 studies. 11 High rates of cardiac involvement and myocardial inflammation (30-50%) were also seen young patients with MISc. 4, 5 This difference to our cohort might be explained by the postulated cytokine storm, which seems not that distinctive in mild COVID-19 disease courses. 12 Despite the small sample size, our study in paediatric patients is pointing to a minor clinical relevance of myocardial involvement in children after mildly symptomatic COVID-19 infections without need for hospitalization or signs of sys-temic inflammation. A routinely diagnostic workup by CMR seems not to be necessary in this patient group. 13 

Outcomes of cardiovascular magnetic resonance imaging in patients recently recovered from coronavirus disease 2019 (COVID-19)

Cardiac involvement in COVID-19 patients: mid-term follow up by cardiovascular magnetic resonance

Early cardiac involvement in patients with acute COVID-19 infection identified by multiparametric cardiovascular magnetic resonance imaging

Multimodality cardiac evaluation in children and young adults with multisystem inflammation associated with COVID-19

Cardiac involvement in patients recovered from COVID-2019 identified using magnetic resonance imaging

Multisystem inflammatory syndrome in children: an international survey

Collaborators of the European Society of Paediatric Radiology Cardiothoracic Task Force

Cardiovascular magnetic resonance findings in non-hospitalized paediatric patients after recovery from COVID-19

Diffuse myocardial fibrosis by T1 mapping is associated with heart failure in pediatric primary dilated cardiomyopathy

Toward evidence-based diagnosis of myocarditis in children and adolescents: rationale, design, and first baseline data of MYKKE, a multicenter registry and study platform

Cardiac magnetic resonance imaging findings in 2954 COVID-19 adult survivors: a comprehensive systematic review

COVID-19 pandemic and troponin: indirect myocardial injury, myocardial inflammation or myocarditis?

Going after COVID-19 myocarditis

We thank Alireza Khasheei for helping with CMR examinations.Open Access funding enabled and organized by Projekt DEAL.

None declared.

This study was not supported by any grant.