Cardiovascular impact of COVID-19 with a focus on children: A systematic review

Table 10 Recommendations for the management of pediatric cases of genetic heart diseases during coronavirus disease-2019 pandemic

Disease	Recommendations for management during COVID-19 pandemic
General recommendations	Preventive measures to minimize SARS-CoV-2 infection: Social distancing, hand-washing, facial mask. Limit outpatient clinic visits and electrophysiological and surgical procedures to life-threatening arrhythmias requiring immediate treatment, non-deferrable treatments and urgent diagnostic devices. Rule-out the presence of ventricular arrhythmia or heart failure when common overlapping COVID-19 symptoms appear: Dyspnea, syncope, cough, fatigue. Aggressive management of fever, diarrhoea and adrenergic stress as the main triggers for cardiac complications. Balance fluid and electrolyte intake according to clinical status. Influenza, pneumococcal and respiratory syncytial virus vaccination are recommended to reduce the possibility of co-infection of COVID-19. Consider at home management as first option whenever possible. Consider initial hospitalization for closely monitoring and intensive treatment in high-risk patients for heart failure or sudden cardiac death episodes. Pediatric cardiologist evaluation is highly advised when hospitalization is required. Careful use of specific COVID-19 treatment (antivirals and immunomodulatory drugs). Not discontinue usual cardiac basal.
LQTS	Avoid hyper-adrenergic states as triggers of Ventricular Tachycardia and Torsade de Pointes. Fever is not a main issue in LQTS. Aggressive control of fever is only recommended for LQTS type-2 cases. Beta-blocker therapy must be continued. QT prolonging drugs should be avoided. Flecainide can interact with antivirals but must not be discontinued. Avoid and correct dehydration states with ion alterations, overall potassium). Check serum electrolyte levels (especially potassium) in case of vomiting and diarrhoea. Keep potassium level above 4mEq/l with potassium supplements. Consider hospitalization in high-risk patients: Previous syncope. High-risk mutation. Infants younger than 1 year-old. Whenever an in-hospital admission is needed, a careful QT monitoring and a telemetric system should be used. Specific therapies for COVID-19 that are known to prolong the QT interval, specially hydroxychloroquine, azithromycin and ritonavir, should be avoided or used with caution.
Brugada	Aggressive management of Fever is the main issue. All patients should self-treat with paracetamol immediately if they develop signs of fever and stay at home. Consider hospitalization in high-risk patients: Children without an ICD and with previous syncope, spontaneous Brugada type-1 pattern on ECG, persistent fever despite paracetamol treatment at home, presence of palpitations or syncope. Management in the hospital should include monitoring of ECG abnormalities and arrhythmia as well as efforts to reduce the body temperature. If an ECG shows the type 1 Brugada ECG pattern, then the patient will need to be observed until fever and/or the ECG pattern resolves. If all ECGs show no sign of the type 1 Brugada ECG pattern, then they can go home. Specific drugs for COVID-19 do not influence on Brugada syndrome patients.
CPVT	At present, there are no data suggesting that patients with CPVT are at increased risk of infection with COVID-19. Avoid hyper-adrenergic states as triggers of Ventricular Tachycardia. Whenever possible, avoid the use of adrenaline in situations of ventricular tachycardia/ventricular fibrillation (VT/VF). Adrenaline is contraindicated in the event of cardiac arrest. Beta-blocker therapy must be continued. QT prolonging drugs should be avoided. Flecainide can interact with antivirals but must not be discontinued. An increased heart rate alone (pacing-induced), as an important symptom of fever or stressful circumstances, does not appear to be sufficient for the induction of ventricular arrhythmias. The antiviral or immunomodulatory therapy proposed for COVID-19 is not expected to influence on CPVT patients.
Cardiomyopathies	Avoid hyper-adrenergic and dehydration states that can provoke or increase left ventricular outflow obstruction leading to syncope and sudden cardiac death in HCM. Avoid hyper-adrenergic states with increased energetic and oxygen consumption leading to a worsening the myocardial function and decompensated heart failure in DCM. Consider hospitalization in high risk patients: Basal left ventricular outflow tract obstruction, end stage cardiomyopathies, decompensated HF with no response to intensification of oral treatment at home, syncope Hospital management include balance fluid and electrolyte intake according to the clinical status. Predisposition to Pulmonary edema. Negative hydric balance in case of pulmonary edema in DCM. Positive hydric balance in case of LVOTO in HCM. ECG monitoring watching for VA. QT monitoring, especially in patients on disopyramide and COVID-19 therapies). Echocardiography is mandatory to assess LVOTO and myocardial function.

COVID-19: Coronavirus disease-2019; SARS-CoV-2: Severe acute respiratory syndrome coronavirus 2; LQTS: Long QT síndrome; CPVT: Catecholaminergic polymorphic ventricular tachycardia; HCM: Hypertrophic cardiomyopathy; DCM: Dilated cardiomyopathy.