The incidence of Covid-19 remains low in children. Numbers are quoted to be between 2% and 12% (depending on testing), with a generally milder course, but with variable symptoms that may mask the viral infection and cause delay in making the diagnosis.
Despite common sense judgement that preexisting cardiac diseases should impose children with CHD to a higher risk this has only rarely been demonstrated to date (31).
The following strategies should minimize risk of cardiac surgery during Covid-19 pandemic:
Paediatric heart catheterization and intervention in Covid-19 patients has been required in exceptional circumstances. Elective cases have in general been postponed from the beginning of the pandemic. Meanwhile, as the numbers of affected children remain low, it seems reasonable to activate the programs while continuing to use personal protective equipment and following institutional flow algorithms for Covid-19 patients, including switch to negative pressure environment in the catheter laboratory if possible. A comprehensive guidance paper addresses most aspects of decision making and resource allocation (32). The subgroup of adults with CHD are likely to have the highest risk within patients with CHD (5) as, at least in complex cases, premature aging of the heart may be present together with limited cardiac reserve, thus lacking the advantage of children that are in general less susceptible to symptomatic SARS-CoV-2 infections.
Heart transplantation / Immunosuppression: While immunosuppression in general enhances the risk for viral infections and increased severity, as has been described for younger children with influenza, this does not seem to be the case in SARS-CoV-2 infections. Data from solid organ transplantation do not show that immunosuppression during Covid-19 pandemic leads to a less favorable outcome. Immunocompromised children, for example those treated for cancer, only rarely needed modifications of their treatment. Accepting that not all patients are tested for Covid-19 at least symptomatic worsening has not been observed (33). Nevertheless, transmission precautions are of paramount importance and should be strictly followed until further knowledge of SARS-CoV-2 impact on the immune system is available (34).