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Castiglioni P, Rampichini S, Corti CG, Mannarino S, Zuccotti G, Calcaterra V, Formenti D, Moriondo A, Maggioni MA, Esposito F, Merati G. COVID-19-Associated Multisystem Inflammatory Syndrome in Children and Cardiovascular Autonomic Control: A Prospective Cohort Study Nine Months after SARS-CoV-2 Infection. J Clin Med 2024; 13:4163. [PMID: 39064202 PMCID: PMC11278032 DOI: 10.3390/jcm13144163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 07/11/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Background: Multisystem Inflammatory Syndrome in Children (MIS-C) has emerged as a severe pediatric complication during the SARS-CoV-2 pandemic, with potential long-term cardiovascular repercussions. We hypothesized that heart rate and blood pressure control at rest and during postural maneuvers in MIS-C patients, months after the remission of the inflammatory syndrome, may reveal long-term autonomic dysfunctions. Methods: We assessed 17 MIS-C patients (13 males; 11.9 ± 2.6 years, m ± SD) 9 months after acute infection and 18 age- (12.5 ± 2.1 years) and sex- (13 males) matched controls. Heart rate and blood pressure variability, baroreflex function, and hemodynamic parameters were analyzed in supine and standing postures. Results: MIS-C patients exhibited reduced heart rate variability, particularly in parasympathetic parameters during standing (pNN50+: 6.1 ± 6.4% in controls, 2.5 ± 3.9% in MIS-C; RMSSD: 34 ± 19 ms in controls, 21 ± 14 ms in MIS-C, p < 0.05), with no interaction between case and posture. Blood pressure variability and baroreflex sensitivity did not differ between groups except for the high-frequency power in systolic blood pressure (3.3 ± 1.2 mmHg2 in controls, 1.8 ± 1.2 mmHg2 in MIS-C, p < 0.05). The MIS-C group also showed lower diastolic pressure-time indices (DPTI) and systolic pressure-time indices (SPTI), particularly in standing (DPTI: 36.2 ± 9.4 mmHg·s in controls, 29.4 ± 6.2 mmHg·s in MIS-C; SPTI: 26.5 ± 4.3 mmHg·s in controls, 23.9 ± 2.4 mmHg·s in MIS-C, p < 0.05). Conclusions: Altered cardiovascular autonomic control may persist in MIS-C patients with, however, compensatory mechanisms that may help maintain cardiovascular homeostasis during light autonomic challenges, such as postural maneuvers. These results highlight the importance of assessing long-term cardiovascular autonomic control in children with MIS-C to possibly identify residual cardiovascular risks and inform targeted interventions and rehabilitation protocols.
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Affiliation(s)
- Paolo Castiglioni
- Department of Biotechnology and Life Sciences (DBSV), University of Insubria, 21100 Varese, Italy; (P.C.); (D.F.); (G.M.)
- IRCCS Fondazione don Carlo Gnocchi, 20148 Milan, Italy
| | - Susanna Rampichini
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20033 Milan, Italy; (M.A.M.); (F.E.)
| | - Carla Giuseppina Corti
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Savina Mannarino
- Pediatric Department, Buzzi Children’s Hospital, 20154 Milan, Italy; (S.M.); (G.Z.)
| | - Gianvincenzo Zuccotti
- Pediatric Department, Buzzi Children’s Hospital, 20154 Milan, Italy; (S.M.); (G.Z.)
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy;
| | - Valeria Calcaterra
- Department of Biomedical and Clinical Sciences “L. Sacco”, Università degli Studi di Milano, 20157 Milan, Italy;
- Department of Internal Medicine and Therapeutics, Università degli Sudi di Pavia, 27100 Pavia, Italy
| | - Damiano Formenti
- Department of Biotechnology and Life Sciences (DBSV), University of Insubria, 21100 Varese, Italy; (P.C.); (D.F.); (G.M.)
| | - Andrea Moriondo
- Department of Medicine and Technological Innovation (DIMIT), University of Insubria, 21100 Varese, Italy;
| | - Martina Anna Maggioni
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20033 Milan, Italy; (M.A.M.); (F.E.)
- Charité—Universitätsmedizin Berlin, Institute of Physiology, Center for Space Medicine and Extreme Environments Berlin, 10117 Berlin, Germany
| | - Fabio Esposito
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, 20033 Milan, Italy; (M.A.M.); (F.E.)
| | - Giampiero Merati
- Department of Biotechnology and Life Sciences (DBSV), University of Insubria, 21100 Varese, Italy; (P.C.); (D.F.); (G.M.)
- IRCCS Fondazione don Carlo Gnocchi, 20148 Milan, Italy
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Khan RS, Ordog T, Hong SD, Schmitz AH, Thattaliyath B, Sharathkumar AA. Evolution of Cardiovascular Findings in Multisystem Inflammatory Syndrome in Children (MIS-C) Across COVID-19 Variants: Common Trends and Unusual Presentations. Pediatr Cardiol 2024; 45:552-559. [PMID: 38261062 DOI: 10.1007/s00246-023-03397-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 12/25/2023] [Indexed: 01/24/2024]
Abstract
Multisystem inflammatory syndrome in children (MIS-C) is a rare condition following COVID-19 infection. Cardiac involvement is common and includes left ventricular systolic dysfunction, cardiac marker elevation, electrocardiogram (ECG) changes, and coronary artery dilation. This single-center retrospective cohort study compares cardiovascular disease between three major SARS-CoV-2 variants and describes the evolution of findings in medium-term follow-up. Of 69 total children (mean age 9.2 years, 58% male), 60 (87%) had cardiovascular involvement with the most common features being troponin elevation in 33 (47%) and left ventricular dysfunction in 22 (32%). Based on presumed infection timing, 61 patients were sorted into variant cohorts of Alpha, Delta, and Omicron. Hospitalization was longer for the Delta group (7.7 days) vs Alpha (5.1 days, p = 0.0065) and Omicron (4.9 days, p = 0.012). Troponin elevation was more common in Delta compared to Alpha (13/20 vs 7/25, p = 0.18), and cumulative evidence of cardiac injury (echocardiographic abnormality and/or troponin elevation) was more common in Delta (17/20) compared with Alpha (12/25, p = 0.013) or Omicron (8/16, p = 0.034). Forty-nine (77%) of the original cohort (n = 69) had no cardiac symptoms or findings beyond 3 months post-hospitalization. Cardiac MRI was performed in 28 patients (between 3 and 6 months post-hospitalization) and was normal in 25 patients (89%). The differences in the variant cohorts may be due to alteration of the immune landscape with higher severity of COVID-19 infection. Despite overall reassuring cardiac outcomes, it is important to note the variability of presentation and remain vigilant with future variants.
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Affiliation(s)
- Rabia S Khan
- Division of Pediatric Cardiology, Department of Pediatrics, UCLA Health Sciences, Los Angeles, CA, USA.
| | | | - Sandy D Hong
- Division of Pediatric Rheumatology, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Anna H Schmitz
- Division of Hospital Medicine, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Bijoy Thattaliyath
- Division of Pediatric Cardiology, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Anjali A Sharathkumar
- Division of Pediatric Hematology, Department of Pediatrics, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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Beaver M, Jepson B, Binka E, Truong D, Crandall H, McFarland C, Williams R, Ou Z, Treemarcki E, Jensen D, Minich LL, Colquitt JL. Baseline Echocardiography and Laboratory Findings in MIS-C and Associations with Clinical Illness Severity. Pediatr Cardiol 2024; 45:560-569. [PMID: 38281215 DOI: 10.1007/s00246-023-03394-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 12/20/2023] [Indexed: 01/30/2024]
Abstract
Children with COVID-associated multisystem inflammatory syndrome (MIS-C) may develop severe disease. We explored the association of admission echocardiographic and laboratory parameters with MIS-C disease severity. This retrospective, single center study of consecutive MIS-C patients (4/2020-12/2021) excluded those with preexisting cardiomyopathy, congenital heart disease, or prior cardiotoxic therapy. Our hypothesis was that worse admission echocardiographic and laboratory parameters were associated with more severe disease based on vasoactive medication use. Univariable and multivariable logistic regression models assessed the association between vasoactive medication use and baseline variables. Of 118 MIS-C patients, median age was 7.8 years (IQR 4.6, 11.8), 48% received vasoactive medication. Higher admission brain natriuretic peptide [OR 1.07 (95% CI 1.02,1.14), p = 0.019], C-reactive protein [OR 1.08 (1.03,1.14), p = 0.002], troponin [OR 1.05 (1.02,1.1), p = 0.015]; lower left ventricular ejection fraction [LVEF, OR 0.96 (0.92,1), p = 0.042], and worse left atrial reservoir strain [OR 0.96 (0.92,1), p = 0.04] were associated with vasoactive medication use. Only higher CRP [OR 1.07 (1.01, 1.11), p = 0.034] and lower LVEF [0.91 (0.84,0.98), p = 0.015] remained independently significant. Among those with normal admission LVEF (78%, 92/118), 43% received vasoactive medication and only higher BNP [OR 1.09 (1.02,1.19), p = 0.021 per 100 pg/mL] and higher CRP [OR 1.07 (1.02,1.14), p = 0.013] were associated with use of vasoactive medication. Nearly half of all children admitted for MIS-C subsequently received vasoactive medication, including those admitted with a normal LVEF. Similarly, admission strain parameters were not discriminatory. Laboratory markers of systemic inflammation and cardiac injury may better predict early MIS-C disease severity.
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Affiliation(s)
- Matthew Beaver
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA.
- Primary Children's Hospital Outpatient Services, 81 N. Mario Capecchi Drive, Salt Lake City, UT, 84113, USA.
| | - Bryan Jepson
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Edem Binka
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Dongngan Truong
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Hillary Crandall
- Department of Pediatrics, Division of Pediatric Critical Care, University of Utah, Salt Lake City, UT, USA
| | - Carol McFarland
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Richard Williams
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - Zhining Ou
- Department of Internal Medicine, Division of Epidemiology, University of Utah, Salt Lake City, UT, USA
| | - Erin Treemarcki
- Department of Pediatrics, Division of Rheumatology, University of Utah, Salt Lake City, UT, USA
| | - Devri Jensen
- Intermountain Primary Children's Hospital, Salt Lake City, UT, USA
| | - L LuAnn Minich
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
| | - John L Colquitt
- Department of Pediatrics, Division of Pediatric Cardiology, University of Utah, Salt Lake City, UT, USA
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Bronicki RA, Tume SC, Flores S, Loomba RS, Borges NM, Penny DJ, Burkhoff D. The Cardiovascular System in Cardiogenic Shock: Insight From a Cardiovascular Simulator. Pediatr Crit Care Med 2023; 24:937-942. [PMID: 37702585 DOI: 10.1097/pcc.0000000000003354] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/14/2023]
Affiliation(s)
- Ronald A Bronicki
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Sebastian C Tume
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Saul Flores
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Rohit S Loomba
- Department of Pediatrics, Chicago Medical School/Rosalind Franklin University of Medicine and Science, Section of Cardiology, Advocate Children's Hospital Chicago, Chicago, IL
| | - Nirica M Borges
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
| | - Daniel J Penny
- Department of Pediatrics, Division of Pediatric Cardiology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX
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Miranda M, Nadel S. Pediatric Sepsis: a Summary of Current Definitions and Management Recommendations. CURRENT PEDIATRICS REPORTS 2023; 11:29-39. [PMID: 37252329 PMCID: PMC10169116 DOI: 10.1007/s40124-023-00286-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/31/2023]
Abstract
Purpose of Review Pediatric sepsis remains an important cause of morbidity and mortality in children. This review will summarize the main aspects of the definition, the current evidence base for interventions discuss some controversial themes and point towards possible areas of improvement. Recent Findings Controversy remains regarding the accurate definition, resuscitation fluid volume and type, choice of vasoactive/inotropic agents, and antibiotic depending upon specific infection risks. Many adjunctive therapies have been suggested with theoretical benefits, although definitive recommendations are not yet supported by data. We describe best practice recommendations based on international guidelines, a review of primary literature, and a discussion of ongoing clinical trials and the nuances of therapeutic choices. Summary Early diagnosis and timely intervention with antibiotics, fluid resuscitation, and vasoactive medications are the most important interventions in sepsis. The implementation of protocols, resource-adjusted sepsis bundles, and advanced technologies will have an impact on reducing sepsis mortality.
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Affiliation(s)
- Mariana Miranda
- Pediatric Intensive Care Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Simon Nadel
- St Mary’s Hospital, Imperial College Healthcare NHS Trust, London, UK
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Editor's Choice Articles for June. Pediatr Crit Care Med 2022; 23:413-414. [PMID: 35703777 DOI: 10.1097/pcc.0000000000002987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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