A Case of Sick Sinus Syndrome With Prolonged Asystole Masquerading as a Transient Ischemic Attack.

Sick sinus syndrome (SSS) is a term used to describe dysfunction of the sinoatrial (SA) node that can lead to various cardiac arrhythmias that predominately manifest in the elderly. Commonly implicated arrhythmias vary from inappropriate bradycardia, tachycardia, sinus pauses, and rarely sinus arrest. Despite being a common reason for permanent pacemaker implantation, little is known regarding the incidence of SSS and there is even less reporting on SSS complicated by prolonged asystole. We present a case highlighting an infrequently observed manifestation of SSS with recurrent, prolonged ventricular asystolic episodes that were causing previously unexplained episodes of confusion and agonal breathing. Our patient was a 75-year-old male with a past medical history of hypertension, dyslipidemia, and prior transient ischemic attacks (TIAs) that presented after an acute mental status change. The initial leading differential diagnosis was believed to be a TIA and he was admitted to neurology service for further evaluation. The patient had recurring episodes of confusion associated with agonal breathing that upon closer review of the cardiac telemetry revealed sinus bradycardia to the 40s interrupted by several prolonged episodes of asystole, the longest lasting 20 seconds. Due to his symptoms and to avoid potential deterioration resulting in hemodynamic instability, the electrophysiology service urgently placed a temporary transvenous pacemaker and then later implanted a leadless pacemaker. On outpatient follow-up, he no longer had episodes of confusion, and no further asystolic episodes were noted on his device check.

Permanent Pacemaker Placement Secondary to Remdesivir Induced Bradycardia: A Case Report.

Remdesivir is approved by the FDA for the treatment of hospitalized coronavirus disease 2019 (COVID-19) patients. It is known to be associated with transient bradycardia that resolves after discontinuation of the drug. We present a case of a 71-year-old male with a history of congestive heart failure, hypertension, and atrial flutter (rate controlled with carvedilol) presented for evaluation of worsening dyspnea, dry cough, and fatigue. His COVID-19 reverse transcription-polymerase chain reaction (RT-PCR) was positive and his chest x-ray showed right mid-lung opacity. Oxygen saturation was 88% on room air. He was started on dexamethasone and remdesivir. Bradycardia was noted on telemetry monitoring 48 hours after starting remdesivir. Carvedilol was discontinued, but the bradycardia persisted. Heart rate reached a nadir of 38 beats per minute (bpm) three days after completion of remdesivir therapy. Due to persistent bradycardia, he received a dual-chamber cardiac pacemaker without any immediate complications. Three months later, his pacemaker interrogation showed 99% ventricular pacing. We recommend that extra caution should be taken when initiating remdesivir therapy in individuals with baseline conduction abnormalities due to the possibility of persistent bradycardia.

Detecting early physiologic changes through cardiac implantable electronic device data among patients with COVID-19.

Background: Cardiac implantable electronic devices (CIEDs) may enable early identification of COVID-19 to facilitate timelier intervention. Objective: To characterize early physiologic changes associated with the onset of acute COVID-19 infection, as well as during and after acute infection, among patients with CIEDs. Methods: CIED sensor data from March 2020 to February 2021 from 286 patients with a CIED were linked to clinical data from electronic health records. Three cohorts were created: known COVID-positive (n = 20), known COVID-negative (n = 166), and a COVID-untested control group (n = 100) included to account for testing bias. Associations between changes in CIED sensors from baseline (including HeartLogic index, a composite index predicting worsening heart failure) and COVID-19 status were evaluated using logistic regression models, Wilcoxon signed rank tests, and Mann-Whitney U tests. Results: Significant differences existed between the cohorts by race, ethnicity, CIED device type, and medical admissions. Several sensors changed earlier for COVID-positive vs COVID-negative patients: HeartLogic index (mean 16.4 vs 9.2 days [P = .08]), respiratory rate (mean 8.5 vs 3.9 days [P = .01], and activity (mean 8.2 vs 3.5 days [P = .008]). Respiratory rate during the 7 days before testing significantly predicted a positive vs negative COVID-19 test, adjusting for age, sex, race, and device type (odds ratio 2.31 [95% confidence interval 1.33-5.13]). Conclusion: Physiologic data from CIEDs could signal early signs of infection that precede clinical symptoms, which may be used to support early detection of infection to prevent decompensation in this at-risk population.

High-Degree Atrioventricular Block in a Patient With Asymptomatic COVID-19 Infection: A Case Report.

The first cases of COVID-19 infection were reported as pneumonia of unknown cause in China in December 2019. While respiratory complications remain the hallmark of the disease, multisystem involvement has been well documented. Cardiovascular involvement with potentially lethal myocarditis has been extensively reported in the literature. Reports of conduction system disturbances are much rarer, especially in patients without other signs of cardiac involvement. We present a case of an 88-year-old male with no prior cardiac history who presented to the hospital with obstipation. He was diagnosed with a small bowel obstruction and underwent a lysis of adhesions. During the hospitalization, he developed intermittent bradycardia with a high-degree atrioventricular (AV) block. A decision was made to implant a permanent pacemaker. During a pre-procedure COVID-19 screen, he was found to be positive for the presence of SARS-CoV-2 RNA. He had no signs of myocardial injury, a transthoracic echocardiogram showed no abnormalities, and he remained free of any respiratory symptoms. While the involvement of the cardiac conduction system has been documented in patients with symptomatic COVID-19 infection, our patient only exhibited conduction abnormalities and remained free of other COVID-19 symptoms. The sole involvement of the conduction system by COVID-19 is rare, especially in patients with otherwise asymptomatic infections. There is no long-term data to suggest whether such conduction abnormalities are temporary or permanent. As such, patients might benefit from the implantation of a permanent pacemaker.

Assessment of pacemaker lead-related infective endocarditis with three-dimensional echocardiography and cardiac computed tomography.

Pacemaker endocarditis is rare and symptoms may be misleading. If missed, it carries significant morbidity and mortality, particularly in the elderly. Advances in multi-modality imaging in recent years have emphasised its role in clinical decision making. This case highlights the ability of multi-modality imaging techniques to individualise diagnosis, management and prognosis in patients with suspected cardiovascular implantable electronic device (CIED) endocarditis.

[Resource requirements in the surgical treatment of COVID­19 patients at a university clinic of maximum care]. / Ressourcenbedarf bei der chirurgischen Behandlung von COVID­19-Patienten in der universitären Maximalversorgung.

BACKGROUND: Surgical procedures in patients suffering from coronavirus disease 2019 (COVID­19) are possible under strict hygiene and protective measures and are currently carried out regularly. This study examined how much additional work this involves. MATERIAL AND METHODS: A structured evaluation of 71 surgical procedures performed at the Augsburg University Hospital between 1 November 2020 until 31 December 2020 was carried out. The operations on COVID­19 patients were compared to procedures on non-COVID­19 patients with respect to temporal, structural and staff resources, exemplified by four interventions: transbrachial embolectomy, total hip arthroplasty (H-TEP), proximal femoral nail antirotation (PFN-A) and new implantations of cardiac pacemakers. RESULTS: The incision to suture times between the interventions in patients with COVID­19 and non-COVID­19 patients did not show any significant differences in any of the four interventions evaluated. The postoperative monitoring in the operating room, which is identified as time-consuming in many interventions, was often circumvented by postoperative transfer to the intensive care unit or by the use of local anesthetic procedures. For major operations, such as H­TEP, the preparation time was shown to be significantly longer (p = 0.037). Furthermore, there was a significantly higher requirement for anesthesia nursing personnel of 1.5 vs. 1.0 (p = 0.02). CONCLUSION: A quantification of the additional effort of operative treatment is difficult due to the already complex care of COVID­19 patients; however, it can be assumed that there is an increased need for additional human and structural resources due to the supply of material from outside the operating room, which is not documented in the standard recording.

Fragility fracture of the fourth rib in a patient with a cardiac pacemaker: an uncommon case.

PURPOSE: In patients with a cardiac pacemaker, pocket-related complications such as nerve impairment or bone fractures are infrequent. We present a man with a fracture of the 4th rib several months after pacemaker implantation. CASE PRESENTATION: A 74-year-old man, with a left prepectoral pacemaker implanted 13 months ago, presented complaining of chest pain. The pain started after a sudden trunk rotation and right arm flexion movement with a crack. There was tenderness to palpation and crepitation over the left upper ribs. Computed tomography identified a non-displaced fracture line in the anterior aspect of the left 4th rib. After kinesiotaping and activity restriction, pain alleviated. CONCLUSION: Pacemaker implantation might have caused shoulder dysfunction and pectoral tightness resulting in reduced flexibility of the trunk. Consequently, a reaching motion of the arm with a trunk rotation might have directed rotational force vectors towards the osteopenic left 4th rib causing a fragility fracture. In elderly with a pacemaker, osteopenia and concomitant sarcopenia may create a predisposition to this atypical complication.

New Onset, Irreversible, Prolonged QT-Interval Requiring Permanent Biventricular Pacemaker in a COVID-19 Patient.

Various electrocardiographic (EKG) manifestations have been reported in patients with coronavirus disease 2019 (COVID-19). There is growing evidence showing that new onset QT-prolongation is a common EKG finding in COVID-19 patients. In this report, we present a case of a 71-year-old man who was found to have a new onset, irreversible, prolonged QT-interval requiring permanent biventricular pacemaker despite testing negative twice for RT-PCR COVID-19 and correction of all known reversible causes. To date, there are a limited number of reports of irreversible QT-prolongation associated with COVID-19. This case report emphasizes the importance of a physician's clinical judgment in the setting of negative RT-PCR COVID-19 testing. A robust systemic inflammatory state seen in active COVID-19 infection is possibly the key mechanism precipitating the new EKG findings.