COVID-19 infection is known to inflict a life-threatening course in those with comorbid illnesses. Very meagre literature on CHD and COVID-19 disease has been published. They can contract severe COVID-19 disease if infected due to cyanosis, heart failure, pulmonary hypertension, cardiac cachexia, malnutrition, and immunocompromised states. During the second wave preoperative screening, all elective cases with COVID-19 positive were scheduled later. Four children needed emergent or urgent surgery. Hence, considering the benefits outweighing the risks, these children were treated for COVID-19 and then operated once negative.
Case report
Tetralogy of Fallot was the primary diagnosis in three patients with incessant, frequent cyanotic spells not controlled by medical management and one child had a large perimembranous ventricular septal defect with reccurent lower respiratory tract infections and severe failure to thrive weighing 4.5 kg at 9 months of age. Such patients are highly susceptible to a life-threatening infection if affected with severe COVID-19. Reference Iribarne, Thourani and Cleveland1
All patients but for one were asymptomatic for COVID-19 disease. The symptomatic child with Tetralogy of Fallot exhibited a mild COVID-19 disease. These patients needed an urgent addressal of their heart defect and hence were admitted and treated for COVID-19. They underwent a baseline complete blood count, liver function tests, C-reactive protein, partial thromboplastin time, prothrombin time, and a chest X-ray. Chest X-rays revealed the pulmonary vascularity in congruence with underlying heart defect with no parenchymal or interstitial infiltrates. C-reactive protein was elevated marginally in three patients with highest value of 8.8 mg/L in a Tetralogy of Fallot patient as shown in Table 1. Cyanotic spells precipitated a dangerous decline in the saturation of Tetralogy of Fallot patients which were managed with supplemental oxygen, intravenous fluids, and beta-blockers titrated to effect. COVID-19 disease was conservatively managed with prophylactic antibiotics, adequate hydration, and multivitamins with strict adherence to isolation and COVID-19 appropriate behaviour. C-Reactive protein was repeated every 48 hours for a quantitative analysis. A repeat COVID-19 antigen test was done when these children exhibited an asymptomatic period for at least 72 hours and negative repeat C-reactive protein. The positive child was given continued care in COVID-19 facility till tested negative. Once negative, they underwent surgical correction without further delay. The time to test COVID-19 negative from admission, and negative result to surgery is given in Table 1.
Table 1. Registry of cases.
The three Tetralogy of Fallot patients underwent a complete intracardiac repair, and the ventricular septal defect child underwent a pericardial patch closure of ventricular septal defect under cardiopulmonary bypass. All patients received intravenous dexamethasone 0.2 mg/kg after induction to circumvent the inflammatory response on pump. Reference Faraoni, Caplan and DiNardo2 Postoperative course was uneventful, and all were fast tracked. None of the patients needed upgradation of antibiotics or steroids. They were weaned off oxygen by 3rd postoperative day and discharged within 1 week.
Discussion
Since COVID-19 pandemic has been declared across the globe, with the health care fraternity combating this disease, the elective surgical work has been affected. With the emergence of the second wave, most of the hospitals being COVID-19 care centres simultaneously addressing other primary specialities like paediatric cardiac surgery, entails subjecting these kids to a greater risk of contracting COVID-19 and its subsequent consequences in the perioperative period. This has led to a conservative approach to manage elective cardiac surgeries. Reference Atalay, Türkcan and Taşoğluİ3
There are limited data regarding the effects of COVID-19 in the paediatric age group and their vulnerability to develop severe COVID-19 disease. However, the Chinese centre for disease control and prevention showed that children less than 10 years constituted only 1% of COVID-19 cases. Reference Giordano and Cantinotti4 It has been theorised to be less infectious in children as ACE2 (the binding protein for SARS-CoV-2) is not as functional as compared to adults. Reference Giordano and Cantinotti4 With continued new strains emerging with each wave, a subsequent wave is expected to affect children to a larger extent.
During the second wave in a span of 1 month, four children with CHD positive for COVID-19 presented with mild symptoms or asymptomatic with a moderate rise in the C-reactive protein levels. They were treated symptomatically for COVID-19. Based on the crisis management strategies by Stephens et al, we took the challenge of operating these children in the same siting after treating COVID-19 to avoid life-threatening conditions. Reference Stephens, Dearani and Guleserian5
In order to avoid a stormy perioperative period and outcome, we followed the concepts laid down by Levy et al Reference Levy, Blumenthal, Chiotos and Dearani6 and Giordano et al. Reference Giordano and Cantinotti4
As per the recommendations from the congenital cardiac anaesthesia society, intraoperative use of steroids to mitigate the inflammatory response of bypass and also fast tracking of these children helped in early recovery. Reference Faraoni, Caplan and DiNardo2 We had no morbidity or mortalities in this subset.
The outcomes of post COVID-19 in paediatric patients undergoing interventions are unknown but we found all our patients behaved similar to their non COVID-19 counterparts postoperatively similar to an adult cohort study by Lopez-Marco et al. Reference Lopez-Marco, Yates and Suarez7 In a study by Rosati et al, among 259 elective adult cases, 2 patients positive with RTPCR and 15 with 2–4 CO-RAD score on CT scan showed no increase in periprocedural complications after surgery. Reference Rosati, Muneretto and Baudo8 Many studies show increase in morbidity and mortality in patients diagnosed with COVID-19 postoperatively. Reference Yates, Balmforth, Lopez-Marco, Uppal and Oo9 Sanders et al demonstrated better outcomes if COVID-19 was diagnosed preoperatively than postoperatively. Reference Sanders, Akowuah and Cooper10
Based on our experience, we would like to emphasise the benefits of addressing a child with CHD should be weighed against the risks of these kids surviving the dual battle against uncorrected CHD and a concurrent COVID-19 illness. Hence, timely intervention will help avoid untoward outcomes in them.
A wait for the termination of COVID-19 pandemic is unjustifiable in select cases and will render most of these patients inoperable or succumb to the primary illness of CHD. Hence, an attempt has been made to share our small experience to revisit the strategies of a conservative approach to the speciality of congenital heart surgery. We suggest that surgeries may be performed safely on children with critical heart disease who recovered from a recent COVID-19 illness as early as 1 week. However, our recommendations need to be validated by a large- scale study.
Acknowledgements
We thank all the clinical team members for their help in delivering efficient medical care. We also thank Dr. Radha Joshi from Sri Sathya Sai Sanjeevani Research Foundation for the technical support.
Financial support
This study was supported by Sri Sathya Sai Health and Education Trust. The authors reported no external funding received.
Conflicts of interest
None.
