P3D252: Cardiac Complications of Mild SARS cov-2 Infection in Pediatric Patients: A Case Series with Follow-up from the EPICC Study

Background: Cardiac complications associated with severe pediatric SARS-CoV-2 infections have been well described, particularly in those afflicted with Multisystem Inflammatory Syndrome in Children (MIS-C). Few studies have described cardiac sequela of SARS-CoV-2 infection in young persons across the spectrum of severity of COVID-19 disease, and even fewer have prospectively surveilled for cardiac complications in patients without cardiac symptoms.

Objective: Describe cardiac abnormalities observed and prospectively followed-up in a series of individuals noted to have post-COVID-19 echo and ECG abnormalities after initially mild to moderate SARS-CoV-2 infection.

Methods: The Epidemiology, Immunology and Clinical Characteristics of Emerging Infectious Diseases with Pandemic Potential (EPICC) study is a multisite, prospective, COVID-19 cohort study of Military Health System (MHS) beneficiaries. EPICC includes a Youth Echo Screening for Cardiac Complications of COVID (YES-C3) module. EPICC Participants eligible for the YES-C3 module were SARS CoV-2 positive, age 0-22 years and without past history of coronary aneurysm, autoimmune disease, or condition preventing performance of cardiac evaluations. Participants were scheduled for transthoracic echocardiogram (echo) and 12 lead electrocardiogram (ECG) at enrollment and 4 weeks, with follow-up echocardiography at 6 or 12 months in those with initial echo abnormalities. All studies were interpreted by a board-certified cardiologist.

Results: Between January 2021 and March 2022, 154 participants were enrolled in the YES C-3 modification and 129 underwent prospective echo and ECG. Among all participants, 4 had echo or EKG cardiovascular abnormalities attributed to COVID-19. All cases with abnormalities were pediatric patients (age 2 to 15), three were unvaccinated; infections were in the pre-Delta (n = 2), Delta (n = 1) and Omicron (n = 1) variant eras. Three cases were initially outpatients (mild-moderate initial COVID-19 illness) without cardiac symptoms and one case presented with MIS-C requiring hospitalization with LV dysfunction and LAD & T wave ECG changes which resolved by 3 months. Amongst the three outpatients who lacked cardiac symptoms, dilation of the right coronary artery, mildly depressed LV systolic function (consistent with a diagnosis of myocarditis), and frequent atrial ectopy (PAC) were the respective abnormalities observed. By 6 months, all echo abnormalities resolved without intervention. Additionally the patient with frequent PACs had resolution of the frequent ectopy and irregular rhythm on 6 month follow-up.

Conclusion: Three pediatric outpatients with mild to moderate SARS-CoV-2 infection lacking any cardiac symptoms were found to have cardiac abnormalities upon prospective cardiac screening. All of them showed full resolution of their abnormalities without any intervention or therapy during their interval follow-up. The long-term resolution of cardiac findings which we observed in this case series may support current guidelines which advise against routine screening echos or ECGs for young persons with milder SARS CoV-2 infections lacking cardiac symptoms.