CASE SERIES OF SEVERE BRADYCARDIA IN COVID-19 PATIENTS: AN UNUSUAL CARDIAC MANIFESTATION

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Cardiac manifestations of coronavirus disease 2019 (COVID-19) including bradyarrhythmias (BA) are well documented. Postulated mechanisms include direct myocardial injury through viral invasion, myocyte hypoxia, angiotensin-II receptor downregulation, hypercytokinemia and medication-related adverse events. Currently, there are no clear guidelines on the management of severe BA in the setting of COVID-19, including the threshold for permanent pacemaker (PPM) placement. We present a retrospective case series involving five COVID-19 patients with no prior history of cardiovascular disease, who developed severe BA of heart rate < 45 beats per minute. CASE PRESENTATION: Three females and two males were included in the series, with a median age of 50 years (IQR 36-61.5). Sinus bradycardia and high degree heart block were seen in two patients each. Most of the patients were noted to have sinus pauses. Inflammatory markers including D-dimer, LDH, and CRP were elevated. The median CRP in our patients was 106 mg/L (IQR 83.2-208.1) and median D-dimer was 5.63 ug/ml (IQR 1.8-13.2). All patients were treated with dexamethasone and remdesivir. However only one patient was on remdesivir on the day of onset of bradycardia. Four patients were critically ill, requiring ICU care with mechanical ventilation. Two patients required temporary transvenous pacing, one was supported on extracorporeal membrane oxygenation, and one was given atropine. No patient required PPM placement. Two deaths were observed but were not due to BA. DISCUSSION: In this single center, retrospective case series, 5 patients with COVID-19 infection developed severe BA prompting intervention. Laboratory findings demonstrated significantly elevated inflammatory markers in all our patients. The median CRP and D-Dimer in our patients was higher than the median inflammatory markers seen in a systematic review of patients with COVID-19 associated bradycardia showing that the patients in our series were suffering from severe inflammatory state. It was also observed that despite having no prior cardiac history, those more critically ill with COVID-19 infection developed severe BA requiring intervention. Conservative management and reversal of the underlying etiology prevented need for PPM implantation despite two patients developing high-grade atrioventricular-block, and one recurrent asystole. CONCLUSIONS: This preliminary data suggests that even severe BA that develops after COVID-19 infection may not require PPM placement. Further studies are required to elucidate implications, assess the reversibility, and clarify potential therapeutic targets including the indications for PPM in COVID-19 associated bradycardia. Reference #1: Nagamine, Todd et al. "Characteristics of bradyarrhythmia in patients with COVID-19: Systematic scoping review.” Pacing and clinical electrophysiology : PACE, 10.1111/pace.14466. 19 Feb. 2022, doi:10.1111/pace.14466 Reference #2: Chinitz, Jason S et al. "Bradyarrhythmias in patients with COVID-19: Marker of poor prognosis?.” Pacing and clinical electrophysiology : PACE vol. 43,10 (2020): 1199-1204. doi:10.1111/pace.14042 DISCLOSURES: No relevant relationships by Dipanjan Banerjee No relevant relationships by Monika Bernas No relevant relationships by Sandeep Randhawa No relevant relationships by Parthav Shah

Nanotechnological interventions for the detection of pathogens through surface marker recognition

Over the centuries, global pandemics of infectious diseases, such as cholera, small pox, influenza and lately covid has severely impacted the world health and economy. Even after the promising development in science and technology, prevention and treatment of infectious diseases are still a major healthcare problem. Pathogens such as bacteria, viruses, fungi, protozoa are mainly responsible for infectious diseases and these express different surface markers viz., lipoproteins, receptors, lipids, glycoproteins, glycopeptides, carbohydrates, etc. Identification of these biomarkers play a crucial role in pathogen detection/identification, its control, and inhibition. Despite advancements in pathogen identification, the standard conventional diagnostic methods still have limitations related to their specificity and sensitivity. So, in this context, researchers have utilized the versatile nanostructure modalities for effective sensing, diagnosis and prognosis of various infectious diseases. This chapter unleashes various nanodiagnostic techniques developed to detect, capture and image infectious pathogens through biomarker recognition which can be used worldwide. © 2022 Elsevier Inc. All rights reserved.

Defer Thy Diuresis

With the spread of the novel coronavirus disease 2019 (COVID-19) pandemic, an alarming number of patients now present with acute respiratory distress syndrome (ARDS). Conservative fluid management with diuresis in the ARDS patients improves lung function and decreases ventilator-dependent days. Several cardiac manifestations have been reported in COVID-19 patients including rhythm disorders, myocarditis, Takotsubo cardiomyopathy and myocardial infarction. A 65-year-old Asian female with a history of hypertension presented to the emergency department with cough, worsening dyspnea and palpitations of one-week duration. Investigations at admission were significant for a positive COVID-19 polymerase chain reaction test with an electrocardiogram (EKG) (Figure 1 Panel-A) revealing inferior ST-elevations. Troponin-T was elevated to 1162 ng/L with bedside echocardiogram revealing inferior hypokinesis. Due to concerns for acute ST-elevation myocardial infarction (STEMI), the patient underwent cardiac catheterization with no obvious coronary artery occlusion. A ventriculogram revealed apical ballooning and the patient was treated for COVID-19 induced Takotsubo cardiomyopathy. The patient developed worsening respiratory distress on hospitalization day 3 requiring oxygen supplementation with a high-flow nasal cannula. Conservative fluid regimen and diuretic therapy were being administered when the patient developed ventricular fibrillation and suffered a cardiac arrest. After successful resuscitation, a repeat EKG (Figure 1 Panel-B) demonstrated new anterior and inferior ST-elevations. The patient required increasing vasopressor support, and a repeat cardiac catheterization to rule out coronary artery thromboembolism induced STEMI was negative. A right heart catheterization revealed elevated SVR with decreased cardiac index. The patient clinically deteriorated despite negative fluid balance with recurrent malignant arrhythmias. A bedside echocardiogram performed revealed persistent apical hypokinesis and systolic anterior motion of anterior mitral leaflet (Figure 1 Panel-C) with flow acceleration at left ventricular outflow tract (LVOT) (Figure 1 Panel-D). Due to concerns of cardiogenic shock secondary to Takotsubo cardiomyopathy with dynamic LVOT obstruction physiology, the patient was treated with liberal intravenous fluid resuscitation and successfully weaned from vasopressor therapy. Although she was successfully extubated 2 days later, the patient, unfortunately, passed away later from a thromboembolic stroke. Severe COVID-19 infections are associated with catecholamine surge which may precipitate Takotsubo cardiomyopathy in the susceptible patient population. Female patients with Takotsubo cardiomyopathy are at increased risk of developing dynamic LVOT obstruction. In these patients, management of shock and ARDS can be challenging as the use of inotropic agents may result in hemodynamic instability. Our patient was successfully hemodynamically stabilized using fluid resuscitation once the inotropic support was withdrawn after identifying dynamic LVOT obstruction.

Fostering Engagement of Underserved Communities with Credible Health Information on Social Media

The COVID-19 pandemic has necessitated rapid top-down dissemination of reliable and actionable information. This presents unique challenges in engaging low-literate communities that live in poverty and lack access to the Internet. We describe the design and deployment of a voice-based social media platform, accessible over simple phones, for actively engaging such communities in Pakistan with reliable COVID information. We developed three strategies to overcome users' hesitation, mistrust, and skepticism in engaging with COVID content. Users were: (1) encouraged to listen to reliable COVID advisory, (2) incentivized to share authentic content with others, and (3) prompted to critically think about COVID-related information behaviors. Using a mixed-methods evaluation, we show that users approached with all three strategies had a significantly higher engagement with COVID content compared to others. We discuss how new designs of social media can enable users to engage with and propagate authentic information. © 2022 ACM.

Teaching students with learning disabilities in a virtual learning environment

COVID-19 brought unprecedented changes in the education sector at all levels globally. These rapid changes have transformed the way teachers are transacting the curriculum in K-12 classrooms. Teachers have had to adapt and depend on a virtual mode to reach students and facilitate student engagement and subsequent learning. In the absence of professional development support, such overnight changes and giant leaps from traditional face-to-face interaction with students have been extremely challenging for teachers and equally stressful for students and their parents. Many teachers describe their helplessness with growing absenteeism and delayed submission of student assignments. It is even more difficult for students with a learning disability to engage virtually for a longer time in front of a computer screen. They often need intensive, one-on-one support from the parent. This chapter aims to highlight the challenges faced by professionals to teach students with specific learning disabilities effectively in a virtual learning environment and identify effective solutions. © 2021, IGI Global.