Myocardial involvement in children with post-COVID multisystem inflammatory syndrome: a cardiovascular magnetic resonance based multicenter international study-the CARDOVID registry

Abstract

Background: Recent evidence shows an association between coronavirus disease 2019 (COVID-19) infection and a severe inflammatory syndrome in children. Cardiovascular magnetic resonance (CMR) data about myocardial injury in children are limited to small cohorts. The aim of this multicenter, international registry is to describe clinical and cardiac characteristics of multisystem inflammatory syndrome in children (MIS-C) associated with COVID-19 using CMR so as to better understand the real extent of myocardial damage in this vulnerable cohort.

Methods and results: Hundred-eleven patients meeting the World Health Organization criteria for MIS-C associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), having clinical cardiac involvement and having received CMR imaging scan were included from 17 centers. Median age at disease onset was 10.0 years (IQR 7.0-13.8). The majority of children had COVID-19 serology positive (98%) with 27% of children still having both, positive serology and polymerase chain reaction (PCR). CMR was performed at a median of 28 days (19-47) after onset of symptoms. Twenty out of 111 (18%) patients had CMR criteria for acute myocarditis (as defined by the Lake Louise Criteria) with 18/20 showing subepicardial late gadolinium enhancement (LGE). CMR myocarditis was significantly associated with New York Heart Association class IV (p = 0.005, OR 6.56 (95%-CI 1.87-23.00)) and the need for mechanical support (p = 0.039, OR 4.98 (95%-CI 1.18-21.02)). At discharge, 11/111 (10%) patients still had left ventricular systolic dysfunction.

Conclusion: No CMR evidence of myocardial damage was found in most of our MIS-C cohort. Nevertheless, acute myocarditis is a possible manifestation of MIS-C associated with SARS-CoV-2 with CMR evidence of myocardial necrosis in 18% of our cohort. CMR may be an important diagnostic tool to identify a subset of patients at risk for cardiac sequelae and more prone to myocardial damage.

Clinical trial registration: The study has been registered on ClinicalTrials.gov, Identifier NCT04455347, registered on 01/07/2020, retrospectively registered.

Keywords: Acute myocarditis; CMR; Children; MIS-C; SARS Cov-2 infection.

Fig. 1

A Number of ventricular segments involved per patient with late gadolinium enhancement (LGE) (n = 18) in group 1. B Frequency of involvement of different left ventricular segments

Fig. 2

Left panel: short axis view of T2 black blood (BB) acquisition with evidence of oedema in the lateral wall of the left ventricle (yellow arrows). Right panel: short axis view of LGE acquisition with evidence of contrast enhancement in the lateral wall of the left ventricle (yellow arrows)

Fig. 3

Left panel: two chamber view of LGE acquisition with evidence of contrast enhancement in the inferior and anterior wall of the left ventricle (yellow arrows). Right panel: four chamber view of LGE acquisition with evidence of contrast enhancement in the lateral wall of the left ventricle (yellow arrow)