SARS-CoV-2 Associated Pediatric Inflammatory Multisystem Syndrome With a High Prevalence of Myocarditis - A Multicenter Evaluation of Clinical and Laboratory Characteristics, Treatment and Outcome.

Introduction: Pediatric inflammatory multisystem syndrome - temporally associated with SARS-CoV-2 infection (PIMS -TS) comprises a new disease entity having emerged after the COVID-19 outbreak in 2019. Materials and Methods: For this multicenter, retrospective study children between 0 and 18 years with PIMS-TS between March 2020 and May 2021 were included, before availability of vaccination for children. Frequent SARS-CoV-2 variants at that period were the wildtype virus, alpha, beta and delta variants. Inclusion criteria were according to the PIMS-TS criteria, proposed by the Royal College of Pediatrics and WHO. Study aim was to review their clinical, laboratory and echocardiographic data with a focus on cardiac involvement. Results: We report 45 patients, median age 9 years, 64% male. SARS-CoV-2 antibodies were positive in 35/41 (85%). PIMS occurrence followed local COVID-19 peak incidence periods with a time lag. The most common symptoms at presentation were fever (98%), abdominal pain (89%) and rash (80%). Fever history of > 5 days was associated with decreased left ventricular function (p = 0.056). Arterial hypotension and cardiac dysfunction were documented in 72% patients, increased brain natriuretic peptide in 96% and increased cardiac troponin in 64% of the children. Echocardiography revealed mitral valve regurgitation (64%), coronary abnormalities (36%) and pericardial effusions (40%). Increased NT-proBNP was significantly associated with the need of inotropics (p < 0.05), which were necessary in 40% of the patients. Treatment comprised intravenous immunoglobulin (93%), systemic steroids (84%) and acetylsalicylic acid (100%; 26/45 started with high dosages). For insufficient response to this treatment, five (11%) children received the interleukin-1 receptor antagonist anakinra. All patients were discharged with almost resolved cardiac signs. Conclusion: Our analysis of non-vaccinated children with PIMS-TS demonstrates that a considerable number have associated myocarditis requiring intensive care and inotropic support. Most children showed adequate response to intravenous immunoglobulin and steroids and good recovery. Further evaluation of pediatric patients with COVID-19 associated diseases is required to evaluate the impact of new virus variants.

Prophylactic Peritoneal Catheter Placement in Congenital Cardiac Surgery.

The use of a peritoneal catheter in selected patients, in relation to the congenital heart defect and surgical procedure, may improve postoperative fluid balance and recovery. The peritoneal catheter allows to either drain ascites passively out of the peritoneal cavity or utilize cycles of peritoneal dialysis. However, potential benefits contrast with risk. This article provides a step-by-step guide on how to implant a peritoneal catheter in the operating room after cardiac surgery, or insert it at the bedside in the ICU, to minimize the risk of complications such as bowel perforation, herniation or omental adhesions.

Double atrioventricular valve replacement using Melody™ transcatheter valves in an infant with unbalanced atrioventricular septal defect: a case report.

BACKGROUND: To the best of our knowledge, this is the first report of a successful one-stage double atrioventricular valve (AVV) replacement using two Melody™ transcatheter valves in an infant. CASE SUMMARY: We report a successful case of double AVV replacement with Melody™ transcatheter valves in a 9-month-old infant with a right ventricular dominant atrioventricular septal defect (AVSD). The boy initially presented with borderline sized left-sided heart structures, congenital left AVV stenosis, ventricular displacement of the right AVV with high-grade insufficiency and moderate valvar pulmonary stenosis. Double AVV replacement was performed 2 months after an unsuccessful attempt to repair the defect with persisting left AVV stenosis, underfilling of the small left ventricle and high-grade right AVV, and pulmonary valve regurgitation, resulting in low cardiac output. During double Melody™ AVV replacement, the right ventricular outflow tract was replaced with a pulmonary homograft. The boy was discharged on post-operative Day 28 and presented with competent valves, no ventricular outflow tract obstruction and no paravalvular leak at 11 months of follow-up. DISCUSSION: The presented innovative approach allowed for biventricular correction of an unbalanced AVSD with unfavourable anatomy for standard techniques. The heart team should decide individualized, after careful assessment of cardiac anatomy and function, if the benefits of replacement of AVVs with Melody™ transcatheter valves may outweigh the benefits of univentricular palliation in case of unbalanced AVSD.

Surgical stented transcatheter valve-in-valve implantation in atrioventricular position in children.

The Melody valve (Medtronic, Minneapolis, MN, USA) is a stented bovine jugular vein graft that was primarily approved for transcatheter implantation in a pulmonary valve position. The prosthetic valve can also be implanted in an atrioventricular position in infants and young children, and in these cases it must be modified appropriately.  In this tutorial we demonstrate the surgical preparation of a stented transcatheter Melody valve for implantation in the atrioventricular position. Additionally, we present a safe and effective method for surgical valve-in-valve implantation in a 3-year-old patient with hypoplastic left heart syndrome.

Course of platelet miRNAs after cessation of P2Y12 antagonists.

BACKGROUND: Circulating platelet micro-RNAs (miRNAs) may be used to monitor platelet function during dual antiplatelet therapy (DAPT). Aim of the study was to measure plasma levels of specific miRNAs (miRNA-223, -150, -21 and -126) after physician-driven cessation of chronic P2Y12 inhibition and to study differences in the expression levels of these miRNAs between the different oral P2Y12 inhibitors clopidogrel, prasugrel and ticagrelor, respectively. DESIGN: Patients with coronary artery disease (CAD) on DAPT maintenance dose (including aspirin 100 mg OD, plus clopidogrel 75 mg OD, or prasugrel 10 mg OD, or ticagrelor 90 mg BID) were prospectively enrolled before cessation of the P2Y12-inhibitor therapy. MiRNA-223, -150, -21 and -126 were determined at baseline (=last day of P2Y12-inhibitor intake) and 10, 30 and 180 days thereafter. RESULTS: Cessation of P2Y12-inhibitor therapy did not significantly change miRNA levels. However, in ticagrelor-treated patients, miRNA levels were significantly increased at baseline (miRNA-223 and -21), day 10 (miRNA-223, -150, -21, -126) and day 30 (miRNA-223, -150, -21, -126) as compared to prasugrel, and at day 10 (miRNA-150 and -21) and day 30 (miRNA-150) as compared to clopidogrel (all P < 0.05). At day 180, only miRNA-126 levels differed significantly with respect to the P2Y12 inhibitor used (P < 0.05). After adjustment for confounders, choice of P2Y12-inhibitor was the strongest predictor of miRNA levels (P < 0.001), while cessation of P2Y12-inhibitor therapy did not significantly impact miRNA levels. CONCLUSION: In patients with CAD, ticagrelor intake is associated with increased levels of platelet miRNAs as compared to clopidogrel and prasugrel. Platelet miRNAs are not useful to monitor platelet function after cessation of P2Y12 inhibitors.

Increased platelet reactivity in dyslipidemic patients with coronary artery disease on dual anti-platelet therapy.

INTRODUCTION: The optimal duration of dual anti-platelet therapy (DAPT) following percutaneous coronary intervention (PCI) is still a matter of debate. Biomarkers may help to identify patients who will benefit from extended DAPT. The aim of the study was to test the interaction between lipid parameters and platelet function in patients with coronary artery disease (CAD) on DAPT. MATERIAL AND METHODS: Overall, 58 patients on DAPT were prospectively included following PCI in stable CAD. Platelet markers, i.e. mean platelet volume (MPV), platelet distribution width (PDW), fraction of reticulated thrombocytes (RT) and ADP-induced multiple electrode aggregometry (MEA), as well as serum lipids, i.e. high-density lipoprotein cholesterol (HDL-C), low-density lipoprotein cholesterol (LDL-C), total cholesterol (TC), triglycerides (TG) and remnant cholesterol (RC), were assessed after intake of a maintenance dose of ASA and P2Y12 inhibitor. RESULTS: A significant inverse correlation was found for HDL-C levels and markers of platelet activation: MPV (r = -0.351, p = 0.009), PDW (r = -0.391, p = 0.003), fraction of RT (r = -0.402, p = 0.003) and ADP-induced MEA (r = -0.345, p = 0.011). Only a weak or no association was found between other lipid parameters and platelet markers. After multivariable adjustment, HDL-C levels served as a strong and significant predictor of MPV (95% CI: -0.039 to -0.009; p = 0.002), PDW (95% CI: -0.094 to -0.034; p < 0.0001), RT (95% CI: -0.107 to -0.031; p = 0.001) and MEA (95% CI: -0.540 to -0.170; p < 0.0001), while TG, LDL-C, RC and TC were not significantly associated with platelet function. CONCLUSIONS: Within lipid parameters, only HDL-C levels are strongly associated with markers of platelet activation in CAD patients on DAPT. Accordingly, detection of dyslipidemia might indicate the need for prolongation of DAPT.