Recovery of cardiac function in COVID-19-related MIS-C quick; coronary outcomes good
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Most pediatric patients with multisystem inflammatory syndrome also had evidence of myocardial injury, but functional recovery was quick with no adverse coronary outcomes, researchers reported.
According to data published in the Journal of the American Heart Association, cardiac markers of deformation improved quickly within the first week and showed continued improvement through follow-up of 3 to 4 months.
COVID-19-related MIS-C
“Multisystem inflammatory syndrome in children (MIS-C) is a newly described hyperinflammatory syndrome associated with antecedent COVID-19 exposure. Cardiovascular involvement is frequent (80% to 85% of cases), including shock, left ventricular dysfunction, coronary artery abnormalities and biochemical evidence of myocardial injury,” Daisuke Matsubara, MD, PhD, cardiologist at the Children’s Hospital of Philadelphia, and colleagues wrote. “The aim of this study is to describe cardiac outcomes during a 3-month follow-up period, to determine the short-term impact of acute myocardial injury caused by MIS-C.”
According to the CDC, MIS-C is a condition in which organ and systems such as the heart, lungs, kidneys, brain, skin, eyes or gastrointestinal organs can become inflamed.
This analysis included 60 controls (mean age, 12 years; 55% boys; 62% white) and 60 patients with MIS-C (mean age, 10 years; 60% boys; 27% white), with echocardiograms and deformation parameters analyzed during the acute phase of COVID-19 infection, the subacute phase (3 days after initial echocardiography), at 1 month (median, 22 days) and at 3 to 4 months.
Return of cardiac function in MIS-C
The researchers defined myocardial injury during the acute phase as troponin I level of 0.09 ng/mL or more or brain-type natriuretic peptide more than 800 pg/mL.
According to the researchers, 70% of patients with MIS-C had evidence of myocardial injury at the time of presentation; however, most of the cardiac markers returned to normal by the subacute stage before hospital discharge. The researchers reported no deaths or unexpected cardiac events during follow-up.
All deformation parameters, including LV global longitudinal strain, peak left atrial strain, longitudinal early diastolic strain rate and right ventricular free wall strain, recovered quickly within the first week, and continued to improve and normalize among patients with MIS-C through the 3-month follow-up, according to the study.
Normalization of both global longitudinal strain and left atrial strain in patients with MIS-C occurred between 3 and 9 days, Matsubara and colleagues wrote.
Researchers reported that 7% of participants with MIS-C had small coronary aneurysms at presentation, all of which resolved.
Nine patients underwent cardiac MRI during follow-up (median 162 days), of whom one had residual edema but no fibrosis, according to the researchers.
“Recovery among these children was excellent,” Anirban Banerjee, MD, professor of clinical pediatrics at the University of Pennsylvania Perelman School of Medicine and an attending cardiologist with the Cardiac Center at the Children’s Hospital of Philadelphia, said in a press release. “These results have important implications for our health care teams managing care for children with MIS-C. Our findings may also provide guidance for a gradual return to playing sports after cardiac clearance 3 to 4 months later. Tests needed for clearance include electrocardiogram and echocardiogram. We also recommend cardiac MRI for children who have highly abnormal baseline cardiac MRI during the acute stage or show evidence of continued severe left ventricle dysfunction.”
References:
- CDC. Multisystem Inflammatory Syndrome (MIS-C). www.cdc.gov/mis-c. Accessed Jan. 18, 2022.
- Heart function recovered quickly in children with COVID-19-related MIS-C condition. https://newsroom.heart.org/news/heart-function-recovered-quickly-in-children-with-covid-19-related-mis-c-condition. Published Jan. 19, 2022. Accessed, Jan. 19, 2022.
Perspective
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Deepika Thacker, MD
The researchers’ data are very consistent in that we are seeing these children recover their cardiac function pretty fast, by echocardiograms, which is a little bit different from what we see with myocarditis of other causes. That is, how quickly they respond to the therapies that we now know we should give them.
In this study: The cardiac MRI data were very limited. Of the 60 patients with MIS-C, only nine had MRIs in the chronic period, of which they found myocardial edema in one patient. That is also along the lines of what we are seeing. Thus, it may be a little bit premature to say that there's absolutely no cardiac involvement at 3 to 6 months only based on the echocardiograms.
We have seen that probably about 10% of our kids do have changes on their MRI at 3 to 6 months from initial diagnosis. Some have myocardial edema, some have fibrosis, some both. On cardiac MRI, late gadolinium enhancement at 3 to 6 months may indicate scarring of the myocardium, which may have long-term effects. Long term follow-up is necessary. Our institution is currently a part of ongoing multicenter studies to look at these kids over a period of 4 years.
We had seen a decline in the number of patients coming in with MIS-C in the late summer, which corresponded to the decline in COVID-19 in general in the community, and then we've seen a big uptick since December. We've had a lot of MIS-C coming in recently and some of these kids are really sick in the acute period. It's very heartening to know, from our experience and then what is published in this study, that these kids do well and recover function on echocardiogram. But long-term follow up with cardiac MRI and clinical surveillance is required. Our understanding of a disease and its effects evolves over a period of time, and the story of MIS-C is still unfolding.
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