Systematic Reviews
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Nov 6, 2020; 8(21): 5250-5283
Published online Nov 6, 2020. doi: 10.12998/wjcc.v8.i21.5250
Cardiovascular impact of COVID-19 with a focus on children: A systematic review
Moises Rodriguez-Gonzalez, Ana Castellano-Martinez, Helena Maria Cascales-Poyatos, Alvaro Antonio Perez-Reviriego
Moises Rodriguez-Gonzalez, Pediatric Cardiology Division, Puerta del Mar University Hospital, Cadiz 11009, Spain
Moises Rodriguez-Gonzalez, Ana Castellano-Martinez, Biomedical Research and Innovation Institute of Cadiz, Puerta del Mar University Hospital, Cadiz 11009, Spain
Ana Castellano-Martinez, Pediatric Nephrology Division, Puerta del Mar University Hospital, Cadiz 11009, Spain
Helena Maria Cascales-Poyatos, Pediatrics Division, Motril-San Antonio Primary Care Center, Motril 18600, Spain
Alvaro Antonio Perez-Reviriego, Pediatrics Division, UGC Pediatria AG Sur Granada, Santa Ana Hospital, Motril 18600, Spain
Author contributions: All the authors participated in the search of evidence and revision of the articles selected; Rodriguez-Gonzalez M designed the review, made the statistical analysis and wrote the first draft of the manuscript; Perez-Reviriego AA, Castellano-Martinez A and Cascales-Poyatos HM revised the first draft of the manuscript; Perez-Reviriego AA and Cascales-Poyatos HM summarized data on the tables of the final manuscript; Castellano-Martinez A made the figure of the final manuscript. 
Conflict-of-interest statement: Authors declare no conflict of interest for this article.
PRISMA 2009 Checklist statement: A PRISMA checklist was used to guide the development of the systematic review.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Moises Rodriguez-Gonzalez, MD, Doctor, Pediatric Cardiology Division, Puerta del Mar University Hospital, 21, Ana de Viya Avenue, Cadiz 11009, Spain. doctormoisesrodriguez@gmail.com
Received: September 1, 2020
Peer-review started: September 1, 2020
First decision: September 13, 2020
Revised: September 16, 2020
Accepted: October 13, 2020
Article in press: October 13, 2020
Published online: November 6, 2020
Processing time: 66 Days and 6.1 Hours
ARTICLE HIGHLIGHTS
Research background

Since the beginning of the pandemic, coronavirus disease-2019 (COVID-19) in children has shown milder cases and a better prognosis than adults. Cardiovascular involvement is emerging as one of the most significant and life-threatening complications of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in adults.

Research motivation

To investigate if cardiovascular involvement could be a significant risk factor for severe COVID-19 in children.

Research objectives

We aimed to summarize the current knowledge about the potential cardiovascular involvement in pediatric COVID-19, in order to give a perspective on how to take care of them during the current pandemic emergency.

Research methods

A literature search to identify publications from January 1st, 2020 until July 31st, 2020. was conducted using PubMed and MEDLINE. Also, the websites of the health organizations including World Health Organization and Centers for Disease Control and Prevention and the website of the Johns Hopkins Coronavirus Resource Center were reviewed to provide up to date numbers and infection control recommendations. The included studies were categorized by whether the study involved previously healthy patients or patients with pre-existing cardiac conditions. For pediatric multisystemic inflammatory syndrome (PMIS) temporally associated with COVID-19, multiple meta-analyses were conducted to summarize the pooled mean proportion of different cardiovascular variables in this population in pseudo-cohorts of observed patients. All the statistical analyses were performed using the STATA 14.0 (StataCorp. College Station, TX, United States).

Research results

We included a total of 193 articles in this review. The most relevant articles were 16 studies with size > 10 patients and with complete data about cardiovascular involvement in children with PMIS, 10 articles reporting sporadic cases of myocarditis, pulmonary hypertension and cardiac arrythmias in previously healthy children, and another 10 studies reporting patients with pre-existing heart diseases. The meta-analysis of 16 studies with size > 10 patients and with complete data about cardiovascular involvement in children with PMIS showed that PMIS affects mostly previously healthy school-aged children and adolescents presenting with Kawasaki disease-like features and multiple organ failure with a focus on the heart, accounting for most cases of pediatric COVID-19 mortality. Out of PMIS cases we identified 10 articles reporting sporadic cases of myocarditis, pulmonary hypertension and cardiac arrythmias in previously healthy children. We also found another 10 studies reporting patients with pre-existing heart diseases. Most cases consisted in children with severe COVID-19 infection with full recovery after intensive care support, but cases of death were also identified. There is an increasing concern about the delay of the diagnosis and adequate management of congenital heart diseases (CHD) complications and a delay of the optimal timings for corrections of some stable CHD due to the pandemic, with a potential direct effect on morbidity and mortality.

Research conclusions

There is still scarce data about the role of cardiovascular involvement in COVID-19 in children. Based on our review, all children (previously healthy or with pre-existing heart disease) with acute COVID-19 requiring hospital admission should undergo a cardiac workup and close cardiovascular monitoring to identify and treat timely life-threatening cardiac complications. The management of the different cardiac conditions should be based on the correspondent clinical guidelines, expert panel recommendations and physician´s experience.

Research perspectives

Although cardiovascular involvement seems to be a crucial risk factor associated with severe pediatric SARS-CoV-2 infection, more evidence in the form of multicenter collaborative studies is necessary to elucidate this association.