COVID-19: Where do our heart warriors stand?
An evidence-based, up-to-date synthesis of the effect of COVID-19 on our children and adults with Congenital Heart Disease
The Coronavirus disease 2019 (COVID-19) is caused by a severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). As of July 3, 2020 there have been close to 11 million cases worldwide with over 521,000 deaths. Adults with underlying heart conditions are at increased risk for severe COVID-19 infection, which has raised concern for our adults and children living with congenital heart disease (CHD).
Children have so far accounted for 1-5% of diagnosed cases. They often have a milder disease than adults and childhood deaths are extremely rare(1). However, there is still concern for our patients with more complex forms of CHD who function with impaired cardio-respiratory systems.
Are children and adults with CHD at higher risk?
While having CHD doesn’t put you at increased risk of contracting COVID-19, it is likely patients with complex forms of CHD are at risk of a more serious infection. To date however there is no good long term data to support this The difficulty for our heart parents and clinicians is working out which of the heart abnormalities may be more susceptible to serious infection.
The patients with CHD who are likely to be in a higher risk group include those with the most severe forms of CHD or those patients whose baseline heart and lung function are impaired, including those requiring medications. Further, patients with other co-existing conditions of their kidneys, liver or immune systems are at higher risk.
Children and adults reported at a higher risk include(2,3);
· Single ventricle patients after Fontan operation
· Chronic cyanosis or patients with reduced ventricle function
· Severe pulmonary hypertension
· Immune-compromised patients
· Unrepaired significant CHD
· Adults with coronary artery disease or systemic hypertension
· Other co-existing conditions such as chronic lung or kidney disease
Why are these patients at increased risk?
It appears COVID-19 can have direct and indirect effects on the cardiovascular system. Direct cardiac manifestations include myocarditis (inflammation of the heart), arrythmia (irregular heart rhythms) and myocardial infarction (heart attack)(4). For patients with impaired organ function, the insult of the COVID-19 infection (or many infections for that matter) may mean the body has less reserve to cope with and overcome the infection.
Patients with a compromised immune system particularly have less defence to fight off the infection. COVID-19 poses a particular challenge for heart transplantation with an impact on donor selection, immunosuppression and post-transplant management(5).
There has been several case reports of CHD babies who have acquired COVID-19 and recovered, but to my knowledge no documented cases of CHD babies who have died from the infection. Of course much of the accurate data we have comes from middle to high income countries, so low socio-demographic countries may be underreported.
Are pregnant women and their babies affected?
There are few published cases on COVID-19 infection occurring during pregnancy. A total of 31 infected pregnant COVID-positive mothers have been reported with no cases of transmission to the neonate(6). Unfortunately two mothers died from COVID related respiratory complications after birth. The authors concluded that while there is no evidence for intrauterine transmission, mothers may be at risk of more serious respiratory complications.
How has COVID-19 affected our cardiac care units?
While the impact of COVID-19 has been less on our paediatric population as a whole, paediatric cardiac centres and their associated neonatal intensive care units (NICU) have had to modify their practice considerably. The cancellation of all elective operating occurred to free up hospital beds and divert resources to areas of need. This also reduced the thoroughfare and therefore transmissibility through the hospitals.
Some cardiac centres such as those in New York had to make unthinkable decisions about which CHD babies would get their surgery; Only the most life-threatening emergencies were prioritised. See below a letter from Dr Emile Bacha, Chief Paediatric Cardiac Surgeon at New York Presbyterian, Morgan Stanley Children’s Hospital to his colleagues and friends outlining their bleak reality.
Heart parents’ anxiety is understandably elevated with surgical delays and wait lists blown-out. Further to this, concerned parents were avoiding taking their children to the emergency department during the peak times so only the sickest of children were presenting. As a flow on effect we are now seeing delayed presentations of sick patients requiring more urgent CHD procedures.
In many cardiac units healthcare workers were redeployed into other areas of the hospital. Interestingly some paediatric hospitals were transformed into the ‘flow-over’ facilities for the non-COVID young adult patients, with the adult hospitals remaining as the dedicated ‘COVID’ hospitals.
With respect to patient medical appointments there has been a global transition to telehealth, and despite operating resuming it seems telehealth will persist for as long as possible and appropriate. The difficulty for CHD children is the need to be physically present for routine echocardiograms.
Right now, one of the most heart-breaking challenges for our heart kids and parents is the restriction on numbers of visitors allowed in the NICU and paediatric wards. While these restrictions seem to be easing (In Australia at least), some NICUs still only allow one parent by the bedside. This has been stressful for parents who otherwise need the support of their family members too.
What precautions should we be taking for our heart kids and adults?
· All the simple steps to reduce infection and spread – Regular hand washing, cough in your elbow, social distancing (1.5 metres apart), avoid large crowds, stay at home wherever possible
· Wearing a mask is not universally indicated in all states and countries; Follow your local government recommendations. As a general rule, wearing a mask to protect yourself or your heart baby may be appropriate where social distancing is not possible. Wear a mask if you have symptoms to reduce transmission to others and minimise touching your face.
· Self-isolate appropriately if you have COVID-19
· If you are a child in a high risk CHD category take additional measures to avoid acquiring the infection. This may include parents working from home, children home-schooling and restricting visitors and family to the house – Discuss your level of risk with your paediatric cardiologist.
· Seek help early from your general practitioner or a psychologist if you or child are experiencing psychological or emotional distress that is affecting your health &/or causing anxiety.
· Be prepared that follow up appointments may occur via telehealth
· If you’re on the waitlist for surgery or a catheterisation procedure, be prepared for delays in elective surgery dates
· Do not delay a presentation to the emergency department if you are concerned your child is unwell or deteriorating. In many cases hospitals have measures in place to reduce the infection risk for high-risk patients.
· If your baby is in the NICU, familiarise yourself with the hospital policies regarding visitors so you can prepare mentally and logistically. You can ask on online CHD groups if other heart parents have recently had procedures at that hospital and what the protocols were at the time; Bearing in mind the playing field is constantly changing.
· If you are pregnant with a baby with CHD take all necessary precautions to reduce acquiring COVID-19 as your risk of complications may be higher. Reassuringly, no intrauterine transmission has been documented to date.
· Appropriately timed influenza vaccine is especially important during COVID-19 pandemic as co-infection may increase the risk of serious respiratory complications(7). Patients and family members over the age of 6 months should be vaccinated unless they have a contraindication.
There are many hotlines that can be contacted if you feel your or others are at risk of harm(3). In Australia some of these include;
Lifeline Australia: 13 11 14
Beyond Blue: 1300 224 636
Kids Helpline: 1800 551 80
Confidential Helpline: 1800 737 732
Mensline: 1300 78 99 78
Relationships Australia: 1300 364 277
References
1. Ludvigsson JF. Systematic review of COVID-19 in children shows milder cases and a better prognosis than adults. Acta Paediatrica, International Journal of Paediatrics. 2020.
2. Association ACH. COVID-19 (Coronavirus): What It Means for Adults with Congenital Heart Disease [Internet]. 2020 [cited 2020 Jul 4]. Available from: https://www.achaheart.org/your-heart/health-information/covid-19-coronavirus-what-it-means-for-adults-with-congenital-heart-disease/
3. HeartKids. COVID-19 (Coronavirus) Update Q&A [Internet]. 2020 [cited 2020 Jun 4]. Available from: https://www.heartkids.org.au/whats-on/news/covid19-update
4. Alsaied T, Aboulhosn JA, Cotts TB, Daniels CJ, Etheridge SP, Feltes TF, et al. Coronavirus Disease 2019 (COVID‐19) Pandemic Implications in Pediatric and Adult Congenital Heart Disease. J Am Heart Assoc. 2020;
5. Clerkin KJ, Fried JA, Raikhelkar J, Sayer G, Griffin JM, Masoumi A, et al. COVID-19 and Cardiovascular Disease. Circulation. 2020.
6. Karimi-Zarchi M, Neamatzadeh H, Dastgheib SA, Abbasi H, Mirjalili SR, Behforouz A, et al. Vertical Transmission of Coronavirus Disease 19 (COVID-19) from Infected Pregnant Mothers to Neonates: A Review. Fetal and Pediatric Pathology. 2020.
7. J Ayer, B Anderson, T Gentles RC. CSANZ POSITION STATEMENT ON COVID-19 FROM THE PAEDIATRIC AND CONGENITAL COUNCIL. 2020.
Other resources
For heathcare professionals: A link to the CSANZ Position Statement on COVID-19 from the paediatric and congenital council