COVID-19 is caused by SARS-CoV-2 virus and has developed into a worldwide pandemic. The virus can affect the cardiovascular system by directly infecting heart cells or causing inflammation. For those with congenital heart disease, risk of serious illness from COVID-19 is higher for those over 70, with complex heart conditions, lung disease, or other health problems. While little is known about effects on those with CHD, children may be less severely affected than adults. Treatment focuses on symptoms, and most cases can be managed at home with self-care.

1. COVID 19 AND
CHD: WHAT WE
SHOULD KNOW?
Dr. Dina Abdelsalam.MD

2. AGENDA
• What’s COVID-19?
• What’s SARS-COV2?
• Effect of COVID-19 on Cardiovascular system.
• Effect of COVID 19 on patients with congenital heart disease:
• Take home messages.

3. WHAT’S COVID 19?
COVID-19 (Coronavirus disease 2019) .
Caused by a novel beta coronavirus severe acute respiratory syndrome
coronavirus 2 (SARS-CoV-2) virus.
 First described in a cluster of patients presenting with pneumonia symptoms in
Wuhan, China, in December of 2019.
Over the past few months, COVID-19 has developed into a worldwide pandemic,
with over 2.614.000 documented cases globally as of April 22, 2020.
The SARS-CoV-2 virus is almost likely of zoonotic origin, but has been shown to
have effective human-to-human transmission

4. SARS-COV2
• A virus
• Tiny infectious agent.
• Only grow in the cell of another organisms
• Viruses are classified by type of the nucleic acid
in their genome (RNA and DNA)
• Its not killed by antibiotics which targets
bacteria.
• It can affect respiratory system (nose, throat,
lungs), heart (new or increased arrhythmias),
and possibly lead to pneumonia and acute
respiratory disease.

5. WHAT’S CORONA VIRUS?

10. HOW IS A COVID-19 CASE DEFINED?

23. COVID-19 AND
CARDIOVASCULUAR
SYSTEM

31. Mechanism of cardiac injury in COVID -19
• Direct cardiac cell injury by the virus (likely through ACE2 mechanism)
• proinflammatory cytokine surge as a result of virus infection.immune
response can cause multiorgan failure and DIC
• Severe hypoxia from acute respiratory damage caused by the virus may
result in oxidative stress and myocardial injury from increased myocardial
oxygen demand in the presence of severe hypoxia due to acute lung injury
(ARDS).
• Lymphopenia is commonly seen in patients who are critically ill, suggesting
that SARS-CoV-2 viral particles can invade lymphocytes and cause targeted
destruction of these cells.

36. COVID 19
AND CHD

37. WHAT IS KNOWN ABOUT HOW COVID-19 AFFECTS
THOSE WITH CONGENITAL HEART DISEASE?
• There is very little known about the impact of COVID-19 Infection on patients
with CHD
• Information suggests that children may not be as severely affected by
COVID-19 as adults.
• Having CHD should not increase the chance of becoming infected.

38. • In China, out of over 2000 children infected, there were 13 critical cases and 1
death. However, older adults and those with cardiovascular disease may be more
likely to have severe COVID-19 symptoms and become very ill when infected.
• This is particularly true for adults with uncontrolled heart conditions such as CHF,
hypertension , or CAD, and for those with chronic lung conditions which occur in
CHD patients (like asthma or pulmonary hypertension).

39. RISK STRATIFICATION

40. PEOPLE WITH CONGENITAL HEART DISEASE WHO ARE AT
PARTICULARLY HIGH RISK OF BECOMING SERIOUSLY ILL
FROM COVID-19 CORONAVIRUS INCLUDE THOSE WHO
are over 70
have complex congenital heart disease (such as single ventricle, cyanosis or
Fontan circulation including total Cavo pulmonary connection).
have lung disease or other medical problems such as diabetes or kidney disease
have pulmonary hypertension (high pressure in the lungs)
have heart failure which causes symptoms such as breathlessness or requires
medication
Heart transplant.
Have reduced immunity including Down syndrome and asplenia.

45. The authors suggest several possibilities why there were so few COVID-19/PAH positive
patients.
 The first possibility is that the PH patient community responded early and quickly to
recommendations for social distancing.
 An alternative hypothesis is that the altered blood vessels or immune cells in the lung in PAH
patients may prevent severe COVID-19 from developing by blocking signals that cause the
immune system to overreact in response to infection.
 Finally, some of the PAH-targeted medications may play a protective role against a patient
developing severe COVID-19 by blocking virus entry into the cell or protecting against lung
distress and injury.
More systematic surveying and additional data to understand the impact of COVID-19 on PH
patients are needed to test the authors’ hypotheses. If there is truly a lower risk of severe
COVID-19 in PAH patients, this may give new clues to understanding coronavirus infection and
lead to new treatments.

47. • Covering your mouth and nose with a cloth face cover when around others.
• Cloth face coverings should not be used on young children under 2 years old, anyone
who has trouble breathing or is unconscious, incapacitated or otherwise unable to
remove the mask without assistance.
• The recommended face coverings are not surgical masks or N-95 respirators, which
must continue to be reserved for health care workers and other first responders.
• Continue to keep 6 feet between you and others. The cloth face covers are not a
substitute for social distancing.

48. • vaccination against influenza and pneumococcal pneumonia
• If possible, regularly scheduled clinic visits should be converted to
telehealth visits to minimize risk of acquiring an infection in the nosocomial
setting
• If patients with CHD experienced symptoms like fever, cough, shortness of
breath, its recommended to seek medical advice.

52. MANAGEMENT OF COVID-19 IN
CHD PATIENTS
• Once a patient with ACHD is diagnosed with COVID-19, the
management of the infection is similar to the general population.
• Most COVID- 19 patients (close to 80% in the Chinese experience) can be managed
expectantly at home with self-care measures .
• The initial data from the United States are similar, and estimates are that 20–30% of
patients are being hospitalized .
• For those that need to be admitted, the treatment is mainly supportive and should
follow the (WHO) guidelines .
• Symptomatic relief with antipyretics, use of supplemental oxygen and management of
comorbid conditions are the cornerstones of therapy.
• The use of antiviral, immune modulating, or antibiotic therapies is at this point not
considered standard of care.

53. • Some patients with COVID-19 may experience cardiac injury and
arrhythmias
• Assessment by routine tools ( Echocardiography ,ECG,and cardiac enzymes
and (BNP))
• For patients who are deteriorating:
• precaution with fluid resuscitation, vasopressors,
• mechanical ventilation and (ECMO) have been successful at supporting
patients through critical illness .
• there have been reports of patients recovering from fulminant myocarditis
with intravenous immunoglobulin and steroids

54. • Given the novel nature of the SARS-CoV-2 virus, there are no known effective
therapies at this time, but the therapies being studied include antiviral (remdesivir,
lopinavir/ritonavir, chloroquine, hydroxychloroquine)
• and anti-inflammatory (tocilizumab, steroids) agents.
• Vaccine development is also underway and is one of the priorities for the WHO
moving forward

55. MEDICATIONS OF CONCERN
• ACE Inhibitors or angiotensin receptor II antagonist
• The British Cardiovascular Society, British Society for Heart Failure and European Society of
Cardiology Council on Hypertension have said that there is no clinical or scientific evidence
to suggest that treatment with an ACE inhibitor should be discontinued because of COVID-
19.
• Aspirin
• patients who are taking aspirin continue on their treatment unless advised differently by
their cardiac team.
• Use of paracetamol versus ibuprofen:
• Although there is as yet no firm evidence, patients should use paracetamol rather than
ibuprofen or other non-steroidal anti-inflammatory drugs (NSAIDs) to control fever and
pain.

56. PREGNANT LADIES AND WITH CONGENITAL
HEART DISEASE?
• Pregnant women with some significant CHDs have been classed as ‘clinically
extremely vulnerable’ and are being advised to stay at home and be “shielded” for
at least 12 weeks:
1. Cyanotic heart conditions (with oxygen saturation less than 92% in room air)
2. Systemic right ventricle (for example with congenitally corrected TGA, or after the
mustard or senning atrial redirection surgery for TGA)
3. CHD with reduced left-sided heart function
4. Symptomatic moderate or severe Heart valve problems (stenosis or
regurgitation)
5. Coronary artery disease
6. Left ventricular hypertrophy.
7. Fontan circulation.

58. The coronavirus pandemic is a rapidly evolving situation, and the medical
community continues to learn more about the virus and how it is spread.
In CHD community : up till now, the incidence of catching COVID-19
infection is similar to non CHD patients.
Children chance of catching infection is less than adult.
However, when having the infection, there is increased incidence of having
more serious illness.
Everyone – including patients with chronic medical conditions – should
practice basic infection control preventions to minimize the risk of getting
or spreading coronavirus.
Take home messages

60. Resources