Bradycardia associated with Multisystem Inflammatory Syndrome in Children with COVID-19: a case series

Abstract Background Multisystem Inflammatory Syndrome in Children (MIS-C) is a rare life-threatening clinical condition that can develop in patients younger than 21 years of age with a history of infection/exposure to Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The cardiovascular system is a main target of the inflammatory process that frequently causes myocardial dysfunction, myopericarditis, coronary artery dilation, hypotension, and shock. MIS-C-associated myocarditis is usually characterized by fever, tachycardia, nonspecific ECG abnormalities and left ventricular dysfunction, but serious tachyarrhythmias may also occur. We report 2 cases of patients with MIS-C-associated myocarditis who developed severe bradycardia. Case summary Two female adolescents with recent history of COVID-19 were initially hospitalized for long-lasting high-grade fever and severe gastrointestinal symptoms. Both patients were diagnosed with MIS-C-associated myocarditis for elevation of markers of myocardial injury (mean highly-sensitive cardiac Troponin 2663 pg/ml, mean NT-pro-BNP 5097 pg/ml) and left ventricular dysfunction, which was subsequently confirmed by cardiac magnetic resonance. Both patients developed a severe sinus bradycardia (lowest HR 36 and 42, respectively), that appeared refractory to the treatment with intravenous Methylprednisolone and Immunoglobulins, despite a clinical and biochemical improvement. The use of Anakinra (a recombinant IL-1 receptor antagonist), was associated with a rapid improvement of cardiac rhythm and excellent clinical outcome at 6 months follow-up. Discussion In patients with MIS-C-associated myocarditis, a continuous cardiac monitoring is mandatory to promptly identify potential conduction abnormalities. Adolescents may present bradycardia as a rhythm complication. We experienced a rapid recovery after treatment with Anakinra, to be considered as add-on therapy in cases refractory to standard anti-inflammatory treatment.

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The Natural History of Severe Acute Respiratory Syndrome Coronavirus 2–Related Multisystem Inflammatory Syndrome in Children: A Systematic Review

Journal of the Pediatric Infectious Diseases Society ◽

10.1093/jpids/piaa112 ◽

2020 ◽

Cited By ~ 3

Author(s):

Stephen C Aronoff ◽

Ashleigh Hall ◽

Michael T Del Vecchio

Keyword(s):

Systematic Review ◽

Natural History ◽

Severe Acute Respiratory Syndrome ◽

Myocardial Dysfunction ◽

Case Reports ◽

Clinical Manifestations ◽

Gastrointestinal Symptoms ◽

Case Series ◽

History Of ◽

Inflammatory Syndrome

Abstract Background The clinical manifestations and natural history of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)–related multisystem inflammatory syndrome in children (MIS-C) are poorly defined. Using a systematic review of individual cases and case series and collating elements of the clinical course, the objective of this study was to provide a detailed clinical description and natural history of MIS-C. Methods Case reports and series of MIS-C were recovered from repeated MEDLINE searches, a single EMBASE search, and table of contents reviews of major general medicine and pediatric journals performed between June 3 and July 23, 2020. Fever, evidence of inflammation, and evidence of organ dysfunction were required for inclusion. Results MEDLINE and EMBASE searches produced 129 articles, and 10 articles were identified from journal contents or article bibliographies; 16 reports describing 505 children with MIS-C comprise this review. Thirty-two children (14.7%) had negative results for SARS-CoV-2 by nucleic acid and/or antibody testing. The weighted median age was 9 years (6 months to 20 years). Clinical findings included fever (100%), gastrointestinal symptoms (88.0%), rash (59.2%), conjunctivitis (50.0%), cheilitis/ “strawberry tongue” (55.7%), or extremity edema/erythema (47.5%). Median serum C-reactive protein, ferritin, fibrinogen, and D-dimer concentrations were above the normal range. Intravenous gammaglobulin (78.1%) and methylprednisolone/prednisone (57.6%) were the most common therapeutic interventions; immunomodulation was used in 24.3% of cases. Myocardial dysfunction requiring ionotropic support (57.4%) plus extracorporeal membrane oxygenation (5.3%), respiratory distress requiring mechanical ventilation (26.1%), and acute kidney injury (11.9%) were the major complications; anticoagulation was used commonly (54.4%), but thrombotic events occurred rarely (3.5%). Seven (1.4%) children died. Conclusions MIS-C following SARS-CoV-2 infection frequently presents with gastrointestinal complaints and/or rash; conjunctivitis, cheilitis, and/or extremity changes also occur frequently. Serious complications occur frequently and respond to aggressive supportive therapy.

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Diversity of Cardiac and Gastrointestinal Presentations of Multisystem Inflammatory Syndrome in Children (MIS-C) Associated with COVID-19: A Case Series

Global Pediatric Health ◽

10.1177/2333794x21996613 ◽

2021 ◽

Vol 8 ◽

pp. 2333794X2199661

Author(s):

Anuja R. Shikhare ◽

Rimsha M. Iqbal ◽

Rabail Tariq ◽

Daniel R. Turner ◽

Bassam M. Gebara ◽

...

Keyword(s):

Kawasaki Disease ◽

Gastrointestinal Symptoms ◽

Case Series ◽

Asymptomatic Infection ◽

Cardiac Monitoring ◽

Delayed Presentation ◽

Terminal Ileitis ◽

Serologic Evidence ◽

Cardiac Manifestations ◽

Inflammatory Syndrome

COVID-19 is generally a benign or asymptomatic infection in children, but can occasionally be severe or fatal. Delayed presentation of COVID-19 with hyperinflammation and multi-organ involvement was recently recognized, designated the Multisystem Inflammatory Syndrome in Children (MIS-C). Six children with MIS-C with molecular and serologic evidence of SARS-CoV-2 infection were admitted to our hospital between May 5, 2020 and June 25, 2020. All had fever and weakness; 4/6 presented with gastrointestinal symptoms. Two children had features of complete Kawasaki disease, 3 had incomplete Kawasaki disease, while 1 had terminal ileitis with delayed onset of circulatory shock. Treatment consisted of intravenous immunoglobulin and aspirin for Kawasaki-like disease. Remdesivir, corticosteroids, and infliximab were used when indicated. Median hospitalization was 7 days. Immediate treatment resulted in rapid clinical improvement. In children presenting with hyperinflammatory syndromes without cardiac manifestations, testing for SARS-CoV-2 RNA and antibodies, with close cardiac monitoring should be pursued due to the manifold presentations of SARS-CoV-2 infection in children.

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Abstract 2294: The Use of Myocardial Deformation Imaging Based on Ultrasonic Pixel Tracking to Identify Reversible Myocardial Dysfunction

Circulation ◽

10.1161/circ.116.suppl_16.ii_501-a ◽

2007 ◽

Vol 116 (suppl_16) ◽

Author(s):

Michael Becker ◽

Mithra Lenzen ◽

Katharina Stempel ◽

Andreas Franke ◽

Malte Kelm ◽

...

Keyword(s):

Left Ventricular Dysfunction ◽

Myocardial Viability ◽

Predictive Value ◽

Ventricular Dysfunction ◽

Myocardial Dysfunction ◽

Radial Strain ◽

Left Ventricular ◽

Myocardial Deformation ◽

Deformation Imaging ◽

Myocardial Deformation Imaging

Objective. Myocardial deformation imaging allows analysis of myocardial Objective. Myocardial deformation imaging allows analysis of myocardial viability in ischemic left ventricular dysfunction. This study evaluated the predictive value of myocardial deformation imaging for improvement in cardiac function after revascularization therapy in comparison to contrast-enhanced cardiac magnetic resonance imaging (ceMRI). Methods and Results. In 53 patients with ischemic left ventricular dysfunction, myocardial viability was assessed using pixel-tracking-derived myocardial deformation imaging and ceMRI to predict recovery of function at 9±2 months follow-up. For each left ventricular segment in a 16-segment model peak systolic radial strain was determined from parasternal 2D echocardiographic views using an automatic frame-by-frame tracking system of natural acoustic echocardiographic markers (EchoPAC, GE Ultrasound), and maximal thickness of myocardial tissue without late enhancement (LE) using ceMRI. Of 463 segments with abnormal baseline function, 227 showed regional recovery. Compared with segments showing functional improvement, those that failed to recover had lower radial strain (15.2±7.5 vs 22.6±6.3 %; p<0.001) and lower thickness without LE (5.2±2.9 vs 8.7±2.2 mm; p<0.001). Using a cut-off of 17.2 % for peak systolic radial strain, functional recovery could be predicted with high accuracy (specificity 85%, sensitivity 70%, area under the curve (AUC) 0.859, 95% CI: 0.825– 0.893). The predictive value of thickness without LE by ceMRI was similar at a cut-off of 8.2 mm (specificity 84%, sensitivity 70%, AUC 0.831, 95% CI: 0.793– 0.870). Conclusion. Myocardial deformation imaging based on frame-to-frame tracking of acoustic markers in 2D echocardiographic images is a powerful novel modality to identify reversible myocardial dysfunction.

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Early natural history of regional left ventricular dysfunction after experimental myocardial infarction

American Heart Journal ◽

10.1016/0002-8703(88)90801-0 ◽

1988 ◽

Vol 115 (3) ◽

pp. 538-546 ◽

Cited By ~ 3

Author(s):

Douglas L. Mann ◽

Rodney A. Foale ◽

Linda D. Gillam ◽

David Schoenfeld ◽

John Newell ◽

...

Keyword(s):

Myocardial Infarction ◽

Natural History ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Left Ventricular ◽

Experimental Myocardial Infarction ◽

History Of

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Mechanisms of takotsubo syndrome

ESC CardioMed ◽

10.1093/med/9780198784906.003.0315 ◽

2018 ◽

pp. 1280-1283

Author(s):

Leonarda Galiuto ◽

Filippo Crea

Keyword(s):

Cell Survival ◽

Left Ventricular Dysfunction ◽

Functional Recovery ◽

Ventricular Dysfunction ◽

Myocardial Dysfunction ◽

Microvascular Dysfunction ◽

Left Ventricular ◽

Takotsubo Syndrome ◽

Microvascular Spasm

The pathogenesis of takotsubo syndrome can be considered the result of a catecholamine surge that, in predisposed and susceptible individuals, produces microvascular spasm responsible for myocardial dysfunction. The reversibility of microvascular dysfunction along with the activation of the cell survival cascade guarantees prompt and complete functional recovery in the majority of patients. Yet, about 20% of patients have serious in-hospital complications probably related to the severity of left ventricular dysfunction and/or lack of resolution. The reasons for these different outcomes are still unknown.

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Natural History of Severe Left Ventricular Dysfunction after Myocardial Infarction

CHEST Journal ◽

10.1378/chest.85.6.744 ◽

1984 ◽

Vol 85 (6) ◽

pp. 744-750 ◽

Cited By ~ 3

Author(s):

Angel Castañer ◽

Amadeo Betriu ◽

Ginés Sanz ◽

J. Carlos Paré ◽

Santiago Coll ◽

...

Keyword(s):

Myocardial Infarction ◽

Natural History ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Left Ventricular ◽

Severe Left Ventricular Dysfunction ◽

History Of

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Evaluation of myocardial function using the Tei index in patients with Kawasaki disease

Cardiology in the Young ◽

10.1017/s1047951109991910 ◽

2009 ◽

Vol 20 (1) ◽

pp. 44-48 ◽

Cited By ~ 10

Author(s):

Gholamhossein Ajami ◽

Mohammad Borzouee ◽

Hamid Amoozgar ◽

Feridoon Ashnaee ◽

Sara Kashef ◽

...

Keyword(s):

Kawasaki Disease ◽

Acute Phase ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Myocardial Function ◽

Myocardial Dysfunction ◽

Left Ventricular ◽

Healthy Children ◽

Tei Index ◽

Systolic And Diastolic Function

AbstractMyocarditis is a well-recognized component of Kawasaki disease, with left ventricular dysfunction occurring in more than half of the patients during the acute phase of the disease. The purpose of our study was to evaluate myocardial function in these patients using the myocardial performance index, also known as the Tei index. In a prospective study, 14 patients underwent echocardiographic evaluation, first at the time of diagnosis of the disease, in its acute phase before treatment with intravenous immunoglobulin and then 2 weeks later after treatment with immunoglobulin. We assessed the Tei-index, the ejection fraction, shortening fraction, and the presence of valvar regurgitation, pericardial effusion, or coronary arterial involvement. As a control, we also assessed 22 healthy children, matched for age and sex with the study population. Of the patients, half had an increased left ventricular Tei-index in the acute phase, as compared with the data obtained after treatment, the index changing from 0.43 ± 0.08 to 0.35 ± 0.06 (p equal to 0.003). An increased index for the right ventricle was found in 5 patients (36%), values being 0.30 ± 0.05 as opposed to 0.26 ± 0.04 (p equal to 0.009). Of the patients, 5 (35.7%) also had decreased ejection fractions and proportional shortening fractions during the acute phase, confirming left ventricular dysfunction. We concluded that the Tei-index, which measures combined systolic and diastolic function, is a simple, sensitive, and accurate tool for estimating global myocardial dysfunction in patients with Kawasaki disease.

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Síndrome metabólica e disfunção ventricular esquerda subclínica

Scientia Medica ◽

10.15448/1980-6108.2016.3.25584 ◽

2016 ◽

Vol 26 (3) ◽

pp. 25584 ◽

Cited By ~ 1

Author(s):

Wilson Cañon Montañez

Keyword(s):

Metabolic Syndrome ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Myocardial Dysfunction ◽

Global Longitudinal Strain ◽

Tissue Doppler ◽

Left Ventricular ◽

Sindrome Metabolica

Recent studies using both conventional and tissue Doppler echocardiography have gathered evidence of myocardial dysfunction in individuals with metabolic syndrome. Recently, two-dimensional speckle-tracking echocardiography (2D-STE) has become a robust method for the detection of subclinical left ventricular dysfunction through quantitative assessment of myocardial deformation. Some studies suggest that metabolic syndrome is associated with longitudinal deformation of the left ventricle and that global longitudinal strain measured by 2D-STE is impaired in individuals with metabolic syndrome. It may be inferred that the early identification of subclinical left ventricular dysfunction and the determination of the role of the components of metabolic syndrome in impaired myocardial contractility can help elucidate and predict the risk of cardiovascular diseases in this syndrome.

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Diagnosing diabetic cardiomyopathy

Heart and Metabolism - Heart Failure in patients with Diabetes ◽

10.31887/hm.2019.80/swheatcroft ◽

2019 ◽

pp. 13-17

Keyword(s):

Diabetic Cardiomyopathy ◽

Left Ventricular Dysfunction ◽

Ventricular Dysfunction ◽

Myocardial Dysfunction ◽

Systolic Dysfunction ◽

Obstructive Coronary Artery Disease ◽

Left Ventricular ◽

Concentric Hypertrophy ◽

Altered Metabolism ◽

Artery Disease

Diabetic cardiomyopathy reflects the presence of structural or functional abnormalities of the myocardium in an individual with diabetes which are not fully explained by other factors known to cause myocardial dysfunction. Diabetes promotes a range of molecular and cellular changes leading to left ventricular concentric hypertrophy, fibrosis, abnormal perfusion, lipid deposition, altered metabolism, diastolic dysfunction, and later progression to systolic dysfunction. Diagnosis of diabetic cardiomyopathy requires identification of such pathological features whilst at the same time excluding other causes of left ventricular dysfunction. In this article, avail- able modalities which can contribute to a diagnosis of diabetic cardiomyopathy are discussed. In most cases a diagnosis of diabetic cardiomyopathy can be reached by echocardiography or cardiac magnetic resonance imaging to detect structural and functional myocardial changes, with computed tomography coronary angiography being employed to exclude obstructive coronary artery disease which could account for left ventricular dysfunction.

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