ABSTRACT
COVID-19 has important implications for the cardiovascular system, including the onset of arrhythmias. Case Report: A 61 years old male admitted to the hospital with dyspnea, cough and fever (39 °C). Blood pressure was 120/60mmHg and oxygen saturation level 89% with respiratory rate of 33 breaths/min. The acute deterioration of respiratory distress needed invasive ventilation. High resolution computed tomography showed bilateral severe interstitial pneumonia. At the admission the ECG showed sinus tachycardia 100beat/min. The nasopharyngeal swab detected SARS-CoV-2 viral RNA. The following day, the respiratory distress worsened and atrial flutter with high ventricular response rate occurred. The echocardiogram showed left ventricular ejection fraction of 50% and signs of increased left ventricular filling pressures. An external electrical cardioversion initially restored sinus rhythm but atrial flutter relapsed early. A second cardioversion was attempted with intravenous amiodarone. Due to the failure of rhythm, rate control strategy with prolonged intravenous full dose of metoprolol, verapamil and digoxin was attempted but ineffective. The persistent ventricular rate of 150 beat/min contributed to deteriorate the respiratory status raising the issue of reverting to invasive mechanical ventilation. We decided to perform transcatheter ablation of atrial flutter to achieve rhythm control. Our option was for a zero fluoroscopy procedure, using three dimensional electroanatomical mapping system (EnSite Precision™). Recommendations from International consensus were followed in order to ensure patient safety and minimize healthcare professionnal exposure. Endocardial mapping confirmed a cavotricuspid isthmus-dependent atrial flutter which was treated with radiofrequency ablation, restoring sinus rhythm. Bidirectional conduction block across the cavotricuspid isthmus was confirmed by activation map. With the restoration of sinus rhythm, the respiratory status improved and oxygen saturation rapidly increased from 84% to 98% and the patient was feeling better. Conclusion: The low efficacy of medical therapy for rate or rhythm control of atrial flutter in critically ill patients is due to several reasons including the trigger constituted by the underlying disease. Transcatheter ablation is relatively simple and the most effective treatment to maintain sinus rhythm in atrial flutter, but, thus far, there are no specific data in the setting of COVID-19.