Background: In the second wave of Covid-19 structural involvement of the heart (isolated) especially in young adults became an established entity. Ante mortem templates for diagnosis based on echocardiography and strain imaging (which correlated with earlier post mortem findings and CMR slides) proved to be sensitive and specific. Paediatric referral of children with isolated unexplained pain chest prompted to study these patients. Because with each successive wave the age of incidence is lowered. In this study we aim to establish that children also can be diagnosed like young adults. In this study we aim to document similarities and differences in findings found in echocardiography and AFI compared to young adults. We also aim to highlight that it is as specific and sensitive as was found in adults Methods: 50 patients of the age group of 8± 2 years who presented with chest pain (unexplained by clinical and routine examination) and those patients who complained of recent onset of decreased effort tolerance were also included. All patients underwent clinical examination, ECG, echocardiography, strain imaging and estimation of inflammatory markers especially D Dimer. All patients underwent TTE and AFI by vivid T9 ultra (G.E healthcare Chicago USA). All the test were done at presentation and repeated after two months and six months Results: At the presentation ECG showed poor R wave progression in anteroseptal leads. D Dimers were significantly raised (3-4 folds). Echo showed thinned out septal endothelium with SEC in basal and mid cavity of left ventricle confirmed with another echo view of LV. SEC was absent in other chambers. No clots were seen. SEC was present in all patients and served as a mandatory diagnostic criterion. SEC was not seen in young adults. Thinning of septum produced an operculum like appearance in the SAX view. Apico-lateral, antero-septal and antero-lateral hypokinesis was observed. 4CH auto EF was reduced by 10% c.f 2CH AFI revealed mild reduced PGLS and reduced regional strain in apical-lateral segment. PSD PSI values near normal. Repeat echo and AFI after six months revealed resolution of SEC, repair of endothelium and recovery of hypo kinetic segment and improved EF of 4 CH Conclusion: Specific patterns of cardiac involvement can be detected on echocardiography and AFI. Documentation of SEC in LV is a mandatory criterion in diagnosis unlike young adults. Echocardiography and AFI can be used as a reliable tool for diagnosis of COVID Heart in the paediatric population also.
Cardiovascular involvement in COVID-19 is now well documented. Evidence accrued from post-mortem studies in the first wave documentation of Endotheliitis and Myocarditis. Post second wave saw incidence of cardiac involvement as the predominant pathology determining morbidity and mortality.
Besides change in Predilection of organ system involvement, it was seen that age of incidence was lowered.
Second wave saw predominant involvement of the heart ( isolated ) between the age group of 16-35 years (which still persists ). Later half of 2023 saw paediatric referral for unexplained chest pain; for Echocardiography.
Age of incidence ranged from 5-13 years.
A specific template of structural involvement and functional abnormality was available by this period.
The same Echocardiographic parameters were tested in these patients whose symptomatology suggested
COVID Heart. Echocardiographic studies revealed presence of all the features and few additional features specific in paediatrics population only. Presence of SEC (Spontaneous Echogenic Contrast) in the basal and mid portion of LV was a universal pathognomonic finding.
Endotheliitis due to direct invasion of virus and Myocarditis by Cytokines storm or direct invasion (still debatable) has now been the two Established pathologies responsible for Cardiac involvement in COVID.
Clinical spectrum range from Mild Troponin elevation to Heart failure can be seen.
CMR & Endomyocardial Biopsy are the gold standard of diagnosis but not feasible.
Hence establishing Valid; Reproducible patterns in 2D Echocardiography and Strain imaging ( many studies have been published now ) along with laboratory test supporting coagulopathy can help establish Echocardiography as a Sensitive diagnostic modality for identifying COVID HEART.
This was a prospective observational study done at a tertiary care centre and results of one year (August 2023 to July 2024 ) were presented.
Patients selection was based on specific symptomatology of severe episodes, transient pain over precordium not linked to any aggravating factor, any diurnal variation.
Associated with palpitation and mild respiratory discomfort.
Each episode tested for 5 to 10 min with spontaneous recovery and back to normal activities; completely Asymptomatic and normal effort tolerance between the episodes.
Another presentation was fatigue and recent onset reduced effort tolerance.
Only those patients who had no previous history of any cardiac illness or had disease of any organ system ( Clinically and by routine investigation )
All patients underwent routine clinical examinations which had to be normal for inclusion in the study.
12 channel ECG was performed in all patients quantitative Troponin-T was done in all studied patients.
All patients underwent 2D TTE and Strain imagine and analysis by Vivid T9 ultra ( G.E. Healthcare system Chicago, USA ).
Echo was repeated after 2 Months and 6 months respectively.
Lab Investigation – .
above all lab investigations was done in all patients
A total of 50 patients were included in this study. The mean age of the study population was 8± 2.4 years; Predominantly males. Chest pain, palpitations and reduced effort tolerance were the most common symptoms ( 80%, 50%, 40% ). Rhythm, disturbance tachycardia, Bradycardia was the most important finding of occasional atrial fibrillation (5 %) .
ECG -:
Lab Results -:
2D TTE and AFI :- a) At Presentation
Following Characteristic findings were observed
- sluggish mid and distal interventricular septum ( LAD ) mild spontaneous Echogenic contrast around mitral valve, mild MR ( Central Jel )
- Mild Hypokinesia with thinning of Antero-Septal (Majority) or Septal (20%) or Anterolateral (few).
- Thinning and Hypokinesia of IVS led to stretching of that segment which resulted in an OPERCULUM like appearance over the rest of the heart in Systolic frame.
- Slight Anterolateral bulge ( junction of Hypokinetic and normal segment .
- Aforesaid Finding led to increase in transverse diameter leading to oval shape in Diastole frame
-Trivial SEC – Mid cavity around mitral valve
- No RWMA observed in other segments
AFI :-
Peak global longitudinal strain was at a lower limit of normal.
Bulls Eye :-
Regional strain was reduced in apicolateral ( in all patients ) followed by Anteroseptal, Septum
And the Anterior segment.
Strain Derived EF :-
4 CH. Ejection fraction reduced with EF 50± 5%-10% less than 2 CH. – EF
2 CH. Ejection Fraction was almost normal 60± 5%
PSD :-
Normal or mild increase in apicolateral segment
PST :-
Mild increase value apicolateral and anteroseptal segment
RV Strain:-
PGLS and Tapse in normal range
LA Strain:-
Reservoir strain was normal and good EF
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