Due to the emerging nature of the coronavirus disease (COVID-19), its effect on children/adults with congenital heart disease (CHD) are yet unknown. In developed countries, the majority of patients undergo effective surgical and/or catheter interventions in childhood. Thus, only a small proportion of patients have residual defects, and may be more prone to COVID-19 complications [1]. However, in a country like India, where large numbers of patients either remain unoperated or are just palliated, there is a possibility that severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection may be detrimental to such patients. Not only the risk of SARS-CoV-2 infection may be higher as compared to age-matched controls, the additive burden of COVID-19 can further compromise the facilities in already scarce cardiac care programs [2]. The categories of pediatric patients with cardiac disease, likely to be at a higher risk of severe COVID-19 disease are: cyanotic congenital heart disease with pulmonary artery hypertension (PAH) or severe cyanosis (SpO2 <80%), acyanotic congenital heart disease with PAH, acyanotic congenital heart disease with severe stenotic lesion, primary or secondary pulmonary hypertension, Eisenmenger syndrome, cardiomyopathy with severe ventricular dysfunction, and post-cardiac transplant patients [3,4].

Using recommended clinical criteria for hospital admission [5,6] in children with congenital heart disease might lead to many of these being hospitalized, who could otherwise have been managed at home. Children with acyanotic CHD with increased pulmonary blood flow have higher than normal resting respiratory rates even in healthy state, and some signs of respiratory distress are present due to heart failure. Children with cyanotic CHD, have low baseline saturation (<92%) and cyanosis due to their cardiac pathology. Due to these reasons, differentiating COVID-19 pneumonia from congenital heart disease can be very difficult. Therefore, in children with CHDs, the admission criteria [5,6] should not be used in isolation for hospitalization. Rather a wholesome clinical evaluation will help in triaging such patients.

Apart from the hemodynamic burden, some of these children might have reduced immunity, due to Down syndrome, DiGeorge syndrome and asplenia and therefore, may be at even higher risk for poor outcomes with COVID-19 infection [7].　 Tele-consultations are being promoted for patients to maintain social distancing to avoid disease spread. In pediatric cardiology programs, teleservices do not suffice because many children suffering from congenital heart disease require surgical intervention or percutaneous intervention or diagnostic catheterization.　　

As children are less susceptible to COVID-19, the threat is indirect i.e. the delay in surgical/per-cutaneous interventions. Depending on local circumstances, many pertinent factors have to be weighed on case-to-case basis. Factors which need to be focused upon include resource utilization, such as anticipated ventilator duration, and ICU stay; clinical status of the patient and risk of delaying intervention, and; risk of exposure for the patient, family, and healthcare staff [8]. During the current situation, where healthcare personnel are themselves contracting the disease, optimal timings for congenital heart surgery [9] may not be practical.　

We do not know much about the COVID-19 disease in children per se and specially in those with heart disease [4,5]. According to the local scenarios, such decisions have to be taken in individual capacity, keeping the interest of the patient as well as health care facility in mind. Providing teleservices and social distancing, triaging the patients into subgroups and focusing on the ones who need immediate intervention is a win-win situation for all the stakeholders viz. patient, family, health care personals, and the community at large.

1. Brida M, Chessa M, Gu H, Gatzoulis MA. The globe on the spotlight: Coronavirus disease 2019 (Covid-19). Int J Cardiol. 2020 April 03. [Epub ahead of print]. Available from: https://www.internationaljournalofcardiology.com/article/S0167-5273(20)31727-7/ fulltext. Accessed May 05, 2020.

2. Saxena A. Congenital heart disease in India: A status report. Indian Pediatr. 2018;55:1075-82.

3. American Heart Association. What do we know about congenital heart disease and coronavirus? Available from: https://www.heart.org/en/news/2020/03/24/what-do-we-know-about-congenital-heart-disease-and-coronavirus. Accessed April 29, 2020.

4. Adult Congenital Heart Association. COVID-19 (Coronavirus): What It Means for Adults with Congenital Heart Disease. Available from: https://www.achaheart. org/your-heart/health-information/covid-19-coronavirus-what-it-means-for-adults-with-congenital-heart-disease/. Accessed April 29, 2020.

5. World Health Organization. Clinical management of severe acute respiratory infection when COVID-19 is suspected. Available from: https://www.who.int/ publications-detail/clinical-management-of-severe-acute-respiratory-infection-when-novel-coronavirus-(ncov)-infection-is-suspected. 　Accessed April 28, 2020.　

6. Ministry of Health and Family Welfare. Directorate General of Health Services EMR Division. Guidance document on appropriate management of suspect/confirmed cases of COVID-19. Available from: https://www.mohfw.gov.in/ pdf/FinalGuidanceonMangae-mentof Covidcasesversion2.pdf. Accessed April 28, 2020.　

7. Tan W, Aboulhosn JJ. The cardiovascular burden of coronavirus disease 2019 (COVID-19) with a focus on congenital heart disease. Int J Cardiol. 2020;309:70-77.

8. Stephens EH, Dearani JA, Guleserian KJ, Overman DM, Tweddell JS, Backer CL, et al. COVID-19: Crisis management in congenital heart surgery. J Thorac Cardiovasc Surg. 2020 [Journal pre-proof]. Available from: https://www.sciencedirect.com/science/article/pii/ S0022522320308618. Accessed May 05, 2020.

9. Saxena A, Relan J, Agarwal R, Awasthy N, Azad S, Chakrabarty M, et al. Indian Guidelines for Indications and Timing of Intervention for Common Congenital Heart Diseases: Revised and Updated Consensus Statement of the Working Group on Management of Congenital Heart Diseases. Abridged Secondary Publication. Indian Pediatr. 2020;57:143-57.