Strain Echocardiography and Myocardial Dysfunction in Critically Ill Children With Multisystem Inflammatory Syndrome Unrecognized by Conventional Echocardiography: A Retrospective Cohort Analysis

Abstract

OBJECTIVES: Multisystem inflammatory syndrome in children is a newly defined complication of severe acute respiratory syndrome coronavirus 2 infection that can result in cardiogenic shock in the pediatric population. Early detection of cardiac dysfunction is imperative in directing therapy and identifying patients at highest risk for deterioration. This study compares the strengths of conventional and strain echocardiography in identifying cardiac dysfunction in critically ill children with multisystem inflammatory syndrome in children and their association with ICU therapeutic needs and clinical outcomes. DESIGN: Retrospective, observational cohort study. SETTING: A large, quaternary care PICU. PATIENTS: Sixty-five pediatric patients admitted to the PICU with the diagnosis of multisystem inflammatory syndrome in children from March 2020 to March 2021. INTERVENTIONS: Global longitudinal strain four chamber was measured retrospectively by strain echocardiography and compared with conventional echocardiography. Cardiac dysfunction was defined by left ventricular ejection fraction less than 55% and global longitudinal strain four chamber greater than or equal to –17.2%. Clinical variables examined included cardiac biomarkers, immune therapies, and ICU interventions and outcomes. MEASUREMENTS AND MAIN RESULTS: Twenty-four patients (37%) had abnormal left ventricular ejection fraction and 56 (86%) had abnormal global longitudinal strain four chamber. Between patients with normal and abnormal left ventricular ejection fraction, we failed to identify a difference in cardiac biomarker levels, vasoactive use, respiratory support needs, or ICU length of stay. Global longitudinal strain four chamber was associated with maximum cardiac biomarker levels. Abnormal global longitudinal strain four chamber was associated with greater odds of any vasoactive use (odds ratio, 5.8; 95% CI, 1.3–25.3; z -statistic, 2.3; p = 0.021). The number of days of vasoactive infusion was correlated with global longitudinal strain four chamber ( r = 0.400; 95% CI, 2.4–3.9; p < 0.001). Children with abnormal strain had longer ICU length of stay (4.5 d vs 2 d; p = 0.014). CONCLUSIONS: Our findings suggest strain echocardiography can detect abnormalities in cardiac function in multisystem inflammatory syndrome in children patients unrecognized by conventional echocardiography. These abnormalities are associated with increased use of intensive care therapies. Evaluation of these patients with strain echocardiography may better identify those with myocardial dysfunction and need for more intensive therapy.

Clinical Subphenotypes of Multisystem Inflammatory Syndrome in Children: An EHR-based cohort study from the RECOVER program

“…Abnormal cardiac strain has been shown to be associated with increased odds of vasoactive support requirement, duration of vasoactive support, and ICU length of stay. 20 An association has also been shown between the degree of inflammation and cardiac injury severity, in particular CRP, troponin and NT-proBNP, 21 as supported by our data.…”

Global Myocardial Strain in Multisystem Inflammatory Syndrome in Children, Kawasaki Disease, and Healthy Children: A Network Meta-Analysis

“…We evaluated the myocardial strain using network metaanalysis. According to whether LVEF was normal or not, previous studies divided MIS-C into two groups: MIS-C with depressed ejection fraction (MIS-C dEF) and MIS-C with preserved ejection fraction (MIS-C pEF) (17)(18)(19). In this Bayesian network metaanalysis, a random-effects model and consistency model were applied (4 chains, 50,000 iterations, and 20,000 per chain).…”

“…LVEF may become a source of heterogeneity of MIS-C studies. Therefore, as suggested by the previous research (17)(18)(19), we divided MIS-C into two subgroups. Meanwhile, we strengthened the evidence of left ventricular deformation of MIS-C by using network meta-analysis and found the difference between these two groups: left ventricular dysfunction of MIS-C dEF group was more severe than KD, but MIS-C pEF group was similar with KD in the acute phase.…”

“…GLS may be a clinical predictor for MIS-C. In patients with higher GLS, they have higher risk of intensive care, mechanical ventilation, or inotropic support ( 16 , 18 , 45 ). Meanwhile, they may stay longer in intensive care unit or hospital ( 18 , 45 ).…”

“…In patients with higher GLS, they have higher risk of intensive care, mechanical ventilation, or inotropic support ( 16 , 18 , 45 ). Meanwhile, they may stay longer in intensive care unit or hospital ( 18 , 45 ). Meanwhile, correlations of GLS with laboratory parameters in patients with MIS-C were reported, such as C-reactive protein, troponin, and brain natriuretic peptide, indicating the presence of myocarditis and cardiac dysfunction ( 13 , 16 , 45 , 49 ).…”