Clinical outcome of COVID-19 in patients with adult congenital heart disease

Abstract

AimsPatients with adult congenital heart disease (ACHD) are a potentially vulnerable patient cohort in case of COVID-19. Some cardiac defects may be associated with a poor COVID-19 outcome. Risk estimation in ACHD is currently based on expert opinion. The aim of this study was to collect clinical outcome data and to identify risk factors for a complicated course of COVID-19 in patients with ACHD.MethodsTwenty-five ACHD centres in nine European countries participated in the study. Consecutive patients with ACHD diagnosed with COVID-19 presenting to one of the participating centres between 27 March and 6 June 2020 were included. A complicated disease course was defined as hospitalisation for COVID-19 requiring non-invasive or invasive ventilation and/or inotropic support, or a fatal outcome.ResultsOf 105 patients with a mean age of 38±13 years (58% women), 13 had a complicated disease course, of whom 5 died. In univariable analysis, age (OR 1.3, 95% CI 1.1 to 1.7, per 5 years), ≥2 comorbidities (OR 7.1, 95% CI 2.1 to 24.5), body mass index of >25 kg/m2 (OR 7.2, 95% CI 1.9 to 28.3) and cyanotic heart disease (OR 13.2, 95% CI 2.5 to 68.4) were associated with a complicated disease course. In a multivariable logistic regression model, cyanotic heart disease was the most important predictor (OR 60.0, 95% CI 7.6 to 474.0).ConclusionsAmong patients with ACHD, general risk factors (age, obesity and multiple comorbidities) are associated with an increased risk of complicated COVID-19 course. Congenital cardiac defects at particularly high risk were cyanotic lesions, including unrepaired cyanotic defects or Eisenmenger syndrome.

Anatomical complexity does not predict outcomes after COVID-19 in adults with congenital heart disease

“…Few studies examining COVID-19 infection in patients with CHD were published prior to Schwerzmann et al Table S1 in the online supplemental material summarizes the 4 available cohorts/case series with more than 50 patients with CHD. Importantly, these additional studies also found that most patients with CHD experienced mild COVID-19 infection: 92% of adults in Sabatino et al 5 and 84% of adults in Lewis et al 6 compared with 70% of patients in Schwerzmann et al 4 did not require hospitalisation.…”

“…Second, the authors' definition of COVID-19 infection included suspected cases, which may overestimate the proportion of patients who did not require hospitalisation. Third, though Schwerzmann et al 4 describe the largest prospective cohort of patients with CHD with COVID-19 infection, the event rate of complicated infection was still low (13/105 patients). Comparatively, Lewis et al 6 and Sabatino et al 5 reported even fewer patients with an outcome of interest in their studies.…”

“…First, most patients with CHD experienced mild infection, which ranged from 70%-92% in the studies discussed. [4][5][6] Similarly, 81% of patients in the general cohort had experienced mild infection. 1 Second, the main predictors of moderate/severe infection in CHD remain patient characteristics, Editorial such as advanced age, increased BMI and multiple comorbidities including a genetic syndrome.…”

“…Relatedly, Schwerzmann et al's assessment of heart failure as a determinant of patient outcome after COVID-19 infection may be limited by small numbers, as they found 10 patients with heart failure as their main defect-related residual problem, of which only one patient experienced a complicated infection. 4 Furthermore, the number of patients with pre-existing clinical heart failure in the authors' table 4 highlights the fact that their analysis of heart failure as a main defect-related residual problem may not capture the full contribution of clinical heart failure or ventricular dysfunction to patient outcomes after COVID-19 infection. 4 Similarly, Lewis et al 6 found that more than mild ventricular dysfunction was associated with duration of hospitalisation but not moderate/severe infection, yet ACHD physiological stage C or D, which was associated with moderate/ severe infection, includes characteristics…”

Perception is not reality when risk stratifying adults with congenital heart disease for COVID-19

“…This study was part of the European collaboration for Prospective Outcome research in Congenital Heart disease (EPOCH), which recently published their results on the independent predictors of death or severe COVID-19 infection in CHD patients. 4 Importantly but unsurprisingly, most clinicians (82%) felt that ACHD patients were not equally at risk. This likely reflects the variability that exists in patients' anatomy and residual sequelae, partly as a consequence of the decades of increasing surgical and interventional expertise.…”