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We discuss 3 patients, 8-10 years old, with significant tricuspid valve dysfunction during initial days of admission for multi-system inflammatory syndrome in children (MIS-C) associated with coronavirus 2019 (COVID-19) infection.
All 3 patients had COVID antibodies and presented in uncompensated shock needing aggressive fluid resuscitation and vasoactive support. Elevated acute inflammatory markers, acute kidney injury (2/3 patients), troponin leak and repolarization abnormality on ECG were present on admission and resolved by discharge. All were treated with intravenous immunoglobulin (IVIG) infusion, high-dose steroids and prophylactic low molecular weight heparin. They were discharged home on aspirin and steroid taper.
All patients had depressed left ventricular systolic function with LVEF of 38-52% and trivial to mild mitral regurgitation. Following fluid resuscitation and administration of IVIG, all patients developed moderate to severe, new-onset tricuspid valve regurgitation (TR) with failure of leaflet coaptation and normal tricuspid regurgitation velocities, with a TR vena contracta of 6-9 mm. Right ventricular (RV) systolic function as measured by fraction area change and TAPSE ranged from low normal to moderately decreased. RV size and tricuspid annular diameter Z score was normal for all patients.
All 3 patients responded to diuresis and fluid restriction and had mild TR at discharge.
Our patients demonstrated an interesting pattern of early, acute onset, moderate to severe tricuspid valve regurgitation, with a wide gap of non-coaptation between the septal and anterior tricuspid valve leaflets leading to a broad central jet of TR. The degree of TR was disproportionate to the degree of RV systolic dysfunction or annular dilatation.
Role of Imaging in Patient Care:
We postulate that the etiology of tricuspid valve dysfunction is a combination of valvulitis / papillary muscle dysfunction, RV diastolic dysfunction and volume overload due to fluid resuscitation and IVIG. The frequency of these findings points to the need for judicious volume resuscitation and slower IVIG infusions in MIS-C.
TR associated with MIS-C in the pediatric population appears to be transient, and responsive to alterations in the patient’s volume status and inflammatory state. This is in contrast to adults, in whom TR with RV dysfunction has been identified as a predictor of mortality.
Cardiology | Pediatrics
Buddhavarapu, Amulya; Shirali, Girish S.; Kaine, Stephen; and Aly, Doaa, "Transient Tricuspid Valvulitis: Another Brief Casualty of COVID-19 in Children" (2021). Posters. 219.