Can COVID-19 (Coronavirus Disease 2019) cause ventricular hypertrophy in juveniles?

COVID-19 and Ventricular Hypertrophy in Juveniles

COVID-19 can potentially cause ventricular hypertrophy in juveniles, primarily through mechanisms related to myocarditis, which can mimic hypertrophic cardiomyopathy due to myocardial edema. 1

Mechanisms of COVID-19-Related Cardiac Involvement in Juveniles

• COVID-19 myocarditis can present with various cardiac manifestations including mimicking hypertrophic cardiomyopathy due to myocardial edema 1
• Cardiac involvement in COVID-19 occurs through multiple pathways:
  • Direct viral injury to myocytes or vascular endothelium 1
  • Activation of inflammatory and thrombotic cascades 1
  • Myocardial stress from increased demand and reduced oxygenation 1
  • Systemic hyperinflammatory response 1

Cardiac Manifestations in Pediatric COVID-19

• Left ventricular (LV) dysfunction has been reported in 20-55% of cases of Multisystem Inflammatory Syndrome in Children (MIS-C) associated with COVID-19 1
• COVID-19 can affect both ventricles, with right ventricular (RV) dysfunction being a common echocardiographic finding in COVID-19 patients 1, 2
• Ventricular hypertrophy may be observed as a result of myocardial edema rather than true hypertrophy 1
• Cardiovascular manifestations in children with COVID-19 can include myocarditis, pericarditis, arrhythmias, coronary aneurysms, and cardiomyopathy 3

Diagnostic Considerations

• Echocardiography is considered first-line imaging for evaluating cardiac involvement in juveniles with COVID-19 1
• Key diagnostic findings that may indicate COVID-related ventricular hypertrophy include:
  • Increased LV wall thickness that cannot be explained by athletic conditioning 1
  • Abnormal ventricular function (ejection fraction <50% should raise suspicion) 1
  • Elevated cardiac biomarkers (troponin T, BNP/NT-proBNP) 1
• Cardiac MRI is recommended in hemodynamically stable patients with suspected myocarditis 1

Clinical Implications and Management

• Juveniles presenting with COVID-19 should be screened for cardiac dysfunction with a thorough cardiac evaluation if they show signs of cardiac involvement 3
• For MIS-C cases with cardiac involvement, combination therapy with intravenous immunoglobulin and glucocorticoids is recommended 3
• Cardiology consultation is recommended for patients with:
  • Abnormal cardiac test results 1
  • Rising cardiac troponin levels 1
  • ECG or echocardiographic abnormalities concerning for myocarditis 1
• Long-term follow-up is important as subclinical ventricular dysfunction may persist even after mild COVID-19 2

Important Distinctions and Caveats

• Increases in LV wall thickness associated with COVID myocarditis must be distinguished from physiologic athletic cardiac remodeling 1
• In young White athletes, LV wall thickness >12 mm is uncommon and should raise suspicion for pathology 1
• In Black male athletes, particularly those in explosive sports, LV wall thickness may be greater but rarely exceeds 15 mm 1
• Most children with COVID-19 cardiac disease fully recover with no lasting cardiac dysfunction, though long-term studies are still needed 3
• Myocarditis following COVID-19 mRNA vaccination is rare but has been observed primarily in young males aged 12-17 years after the second vaccine dose 1, 4

Monitoring and Follow-up

• Echocardiography with strain evaluation should be considered to assess ventricular function 3
• Continuous cardiac monitoring is recommended for patients admitted with severe acute COVID-19 3
• Laboratory testing should include troponin and BNP/NT-proBNP when clinically indicated 3
• Follow-up echocardiography is important to monitor for resolution of ventricular hypertrophy and normalization of cardiac function 1