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The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic has led to the emergence of a wide range of complications, including those affecting the cardiovascular system. In this case series, we present four patients who developed complete atrioventricular block, a serious and potentially life-threatening heart rhythm disorder, during the course of their coronavirus disease 2019 (COVID-19) illness. The mechanisms by which SARS-CoV-2 may lead to arrhythmias are not fully understood but may involve direct infection and damage to heart tissue, as well as inflammation and cytokine storms. The extent and duration of complete heart block varied among these cases, highlighting the need for further research to understand the spectrum of disease and to improve mortality and morbidity in future waves of SARS-CoV-2 infections. We hope that this case series will draw attention to this serious complication of COVID-19 and inspire further research to improve management and outcomes for affected patients.
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Case Presentation: A 10 year old male with prior COVID-19 exposure presented with 7 days of fever, rash, cough, vomiting, and hypotension. Laboratory evaluation was notable for SARS-CoV2 antibodies, elevated cardiac enzymes, BNP, and inflammatory markers. Initial echocardiogram showed normal cardiac function and a small LAD coronary aneurysm. He was diagnosed with Multisystemic Inflammatory Syndrome in Children (MIS-C) and given methylprednisolone and IVIG. Within 24 hours, he developed severe LV dysfunction and progressive cardiorespiratory failure requiring VA-ECMO cannulation and anticoagulation with bivalirudin. Cardiac biopsy demonstrated lymphocytic infiltration consistent with myocarditis. On VA-ECMO, he had transient periods of complete AV block. With immunomodulator treatment (anakinra, infliximab) and 5 days of plasmapheresis, inflammatory symptoms and cardiac function improved. He weaned off ECMO, and anticoagulation was transitioned to enoxaparin. He had left sided weakness 5 days later, and brain MRI revealed an MCA infarct. Ten days later, he had focal right sided weakness and repeat MRI showed multiple hemorrhagic cortical lesions, thought to be thromboembolic with hemorrhagic conversion secondary to an exaggerated inflammatory response to an MSSA bacteremia in the setting of MIS-C. Enoxaparin was discontinued. After continued recovery and a slow anakinra and steroid wean, he has normal coronary arteries, cardiac function, and baseline ECG but requires ongoing neurorehabilitation. Discussion(s): COVID-19 infection in children is often mild, but MIS-C is an evolving entity that can present with a wide range of features and severity. This case highlights two concepts. While first degree AV block is often reported in MIS-C, there is potential for progression to advanced AV block. Close telemetry monitoring is critical, especially if there is evidence of myocarditis. MIS-C shares features with Kawasaki disease, with a notable difference being a higher likelihood of shock and cardiac dysfunction in MIS-C. In MIS-C patients with cardiovascular collapse requiring ECMO, there is a risk for stroke. There should be a low threshold for neuroimaging and multidisciplinary effort to guide anticoagulation in these complex cases.
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Purpose of study Since mid-April 2020 in Europe and North America, clusters of pediatric cases with a newly described severe systemic inflammatory response with shock have appeared. Patients had persistent fevers >38.5 C, hypotension, features of myocardial dysfunction, coagulopathy, gastrointestinal symptoms, rash, and elevated inflammatory markers without other causes of infection. The World Health Organization, Centers for Disease Control, and Royal College of Paediatrics associated these symptoms with SARS-CoV-2 as multisystem inflammatory syndrome in children (MIS-C). Cardiac manifestations include coronary artery aneurysms, left ventricular systolic dysfunction evidenced by elevation of troponin-T (TnT) and pro-B-type naturietic peptide (proBNP), and electrocardiogram (ECG) abnormalities. We report the clinical course of three children with MIS-C while focusing on the unique atrioventricular (AV) conduction abnormalities. Case #1:19-year-old previously healthy Hispanic male presented with abdominal pain, fever, and non-bloody diarrhea for three days. He was febrile and hypotensive (80/47 mmHg) requiring fluid resuscitation. Symptoms, lab findings, and a positive COVID-19 antibody test were consistent with MIS-C. Methylprednisolone, intravenous immunoglobulin (IVIG), and enoxaparin were started. He required epinephrine for shock and high flow nasal cannula for respiratory distress. Initial echocardiogram demonstrated a left ventricular ejection fraction (LVEF) of 40% with normal appearing coronaries. Troponin and proBNP were 0.41 ng/mL and proBNP 15,301 pg/mL respectively. ECG showed an incomplete right bundle branch block. He eventually became bradycardic to the 30s-50s and cardiac tracing revealed a complete AV block (figure 1a). Isoproterenol, a B1 receptor agonist, supported the severe bradycardia until the patient progressed to a type 2 second degree AV block (figure 1b). A second dose of IVIG was administered improving the rhythm to a type 1 second degree AV block. An IL-6 inhibitor, tocilizumab was given as the rhythm would not improve, and the patient soon converted to a first-degree AV block. Cardiac magnetic resonance imaging showed septal predominant left ventricular hypertrophy and subepicardial enhancement along the basal inferior/anteroseptal walls typical for myocarditis. Case #2: 9-year-old previously healthy Hispanic male presented after three days of daily fevers, headaches, myalgias, diffuse abdominal pain, and ageusia. He was febrile, tachycardic, and hypotensive (68/39 mmHg). Hypotension of 50s/20s mmHg required 3 normal saline boluses of 20 ml/kg and initiation of an epinephrine drip. Severe hypoxia required endotracheal intubation. After the MIS-C diagnosis was made, he was treated with IVIG, mehtylprednisolone, enoxaparin, aspirin, and ceftriaxone. Due to elevated inflammatory markers by day 4 and patient's illness severity, a 7-day course of anakinra was initiated. Initial echocardiogram showed mild tricuspid and mitral regurgitation with a LVEF of 35-40%. Despite anti-inflammatory therapy, troponin and proBNP were 0.33 ng/mL and BNP of 25,335 pg/mL. A second echocardiogram confirmed poor function so milrinone was started. Only, after two doses of anakinra, LVEF soon normalized. Despite that, he progressively became bradycardic to the 50's. QTc was prolonged to 545 ms and worsened to a max of 592 ms. The aforementioned therapies were continued, and the bradycardia and QTc improved to 405 ms. Patient #3: 9-year-old African American male presented with four days of right sided abdominal pain, constipation, and non-bilious non-bloody emesis. He had a negative COVID test and unremarkable ultrasound of the appendix days prior. His history, elevated inflammatory markers, and positive COVID- 19 antibody were indicative of MIS-C. He was started on the appropriate medication regimen. Initial ECG showed sinus rhythm with normal intervals and echocardiogram was unremarkable. Repeat imaging by day three showed a decreased LVEF of 50%. ECG had since changed to a right bundle branch block. Anakinra as started and steroid dosing was increased. By day 5, he became bradycardic to the 50s and progressed to a junctional cardiac rhythm. Cardiac function normalized by day 7, and anakinra was subsequently stopped. Thereafter, heart rates ranged from 38-48 bpm requiring transfer to the pediatric cardiac intensive care unit for better monitoring and potential isoproterenol infusion. He remained well perfused, with continued medical management, heart rates improved. Methods used Retrospective Chart Review. Summary of results Non-specific T-wave, ST segment changes, and premature atrial or ventricular beats are the most often noted ECG anomalies. All patients initially had normal ECGs but developed bradycardia followed by either PR prolongation or QTc elongation. Two had mild LVEF dysfunction prior to developing third degree heart block and/or a junctional escape rhythm;one had moderate LVEF dysfunction that normalized before developing a prolonged QTc. Inflammatory and cardiac markers along with coagulation factors were the highest early in disease course, peak BNP occurred at approximately hospital day 3-4, and patient's typically had their lowest LVEF at day 5-6. Initial ECGs were benign with PR intervals below 200 milliseconds (ms). Collectively the length of time from initial symptom presentation till when ECG abnormalities began tended to be at day 8-9. Patients similarly developed increased QTc intervals later in the hospitalization. When comparing with the CRP and BNP trends, it appeared that the ECG changes (including PR and QTc elongation) occurred after the initial hyperinflammatory response. Conclusions Although the mechanism for COVID-19 induced heart block continues to be studied, it is suspected to be secondary to inflammation and edema of the conduction tissue. Insufficiency of the coronary arterial supply to the AV node and rest of the conduction system also seems to play a role. Although our patients had normal ECG findings, two developed bundle branch blocks prior to more complex rhythms near the peak of inflammatory marker values. Based on the premise that MIS-C is a hyperinflammatory response likely affecting conduction tissue, our group was treated with different regimens of IVIG, steroids, anakinra, and/or tocilizumab. Anakinra, being an IL-1 inhibitor, has been reported to dampen inflammation in viral myocarditis and tocilizumab has improved LVEF in rheumatoid arthritis patients. Based on our small case series, patient's with MISC can have AV nodal conduction abnormalities. The usual cocktail of IVIG and steroids helps;however, when there are more serious cases of cardiac inflammation, adjuvant immunosuppresants like anakinra and toculizumab can be beneficial. (Figure Presented).
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Myocarditis accompanied by a high-grade atrioventricular (AV) block is a rare manifestation of COVID-19 infection. A 53-year-old woman presented with an episode of syncope, dyspnea, dry cough, and fever. On physical examination, the patient had high blood pressure and bradycardia. Her electrocardiography displayed a complete AV block with a junctional escape rhythm. Laboratory investigations revealed leukocytosis, elevated D-dimer, a positive SARS-CoV-2 nasopharyngeal swab, and a significant elevation in troponin. No reversible cause of the AV block was found, and the complete AV block persisted after the complete treatment of COVID-19. A His bundle permanent pacemaker was then implanted. An endomyocardial biopsy demonstrated endomyocardial tissue with focal hemorrhage, fatty infiltration in the endocardium, and active chronic inflammation, supporting the diagnosis of myocarditis. Several hypotheses of complete heart block in COVID-19 infection have been proposed, including direct myocardial injury and enhanced inflammatory response. A persistent total AV block following complete COVID-19 treatment is an indication for permanent pacemaker implantation.Copyright © 2023, Iranian Heart Association. All rights reserved.
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We present the case of a 56-year-old lady who presented with symptomatic bradycardia and was outsourced for permanent pacemaker implantation. The discussion that follows highlights the growing need for permanent pacemakers globally and in Trinidad and Tobago, as well as the stepwise approach needed for investigating patients with symptomatic bradycardia. Finally, recommendations are made for policy changes needed at the national level.
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Introduction: Early reports from China estimated that overall cardiac arrhythmia prevalence in patients hospitalized for COVID-19 was 17%. A higher arrhythmia incidence (44%) was observed in patients admitted to intensive care unit. The industrial workforce was affected by COVID-19 to a great extent. A noteworthy proportion also suffered from cardiac abnormalities. Objective(s): To determine the incidence of arrhythmia in patients with COVID-19 among the industrial workforce using remote patient monitoring technology. Material(s) and Method(s): This was a retrospective, observational, descriptive study of the industrial workforce from Telangana State, India. Approval of the institutional ethics committee was obtained. The need for informed consent was waived off. Patients who tested positive for COVID-19 by RTPCR and aged above 18 years were eligible. The five-day recording of lead-2 ECG on Vigo Monitoring Solution (Connect Care India Pvt. Ltd) was collected and analysed. Brady-arrhythmia during day time, second degree AV block Type-2 (Mobitz II) during the day time, complete heart block, wide QRST, non-sustained ventricular tachycardia and sinus pause were considered "clinically significant". The other sub-types were defined as "clinically non-significant". The ECGs with regular sinus rhythm were interpreted as "normal". The prevalence of clinically significant, clinically non-significant and normal heart rhythm are described here. Result(s): Out of 240 COVID-19 patients who were on-board for remote monitoring, 216 (148 male and 68 female, mean age 51+/-15 years) met the eligibility criteria and only their ECG were analysed. Among them, 18 were known diabetics, 40 were hypertensive and 31 had both comorbidities. 112 were asymptomatic and 104 were symptomatic. The burden of arrhythmia was found clinically significant in 12 (5.6%) patients, clinically non-significant in 87 (40.4%) and normal among 117 (54%) out of 216 patients. Conclusion and Recommendation: The remote patient monitoring may be utilized as a tool for early screening of significant arrhythmia which are to be addressed immediately for better clinical outcome. These devices on being integrated into COVID-19 management strategies may contribute to patient satisfaction, emergency alerts, timely management, reducing mortality rate and enhancing the safety of healthcare providers.
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Objectives: To study the clinico-electrophysiological profile of patients with Infrahisian Wenckebach (IHW) conduction. Material(s) and Method(s): Patients with a clinical diagnosis of atrioventricular (AV) block who underwent permanent pacemaker implantation (PPI) based on standard indications from July 2021-June 2022 at The Madras Medical Mission were subjected to pre-implant Electrophysiology study to document conduction pathology. Result(s): A total of 94 patients underwent PPI for AV block during the study period. EPS was performed in all but one patient (COVID pneumonia). The incidence of IHW was 9/93 (9.6%) of patients with AV block. There is no gender predisposition (M-4, F-5) and their mean age was 71.4 +/- 11.7 years. As many as half of the patients (5/9) had an underlying narrow QRS. The mean QRS duration was 130 +/- 19.3. Ischemic heart disease affected half of the patients and cardiomyopathy in 4/9 patients (mean EF 45.1 +/- 13.7%). Presentation was syncope in all, mean NYHA class was 2.1. Presentation ranged from isolated 1st-degree AV block (1/9) to tri-fascicular block (3/9). In EP study, the mean basal HV interval was 94.7 +/- 27.1 ms. IHW was noted spontaneously in 4 patients and on atrial pacing in the remaining. In the literature, a total of 11 documented cases have been reported (8 case reports). Unlike typical Wenckebach, the increment in PRI is minimal in the 2nd beat of the train. Conclusion(s): Wenckebach periodicity is classically considered an AV nodal phenomenon. IHW is scarcely reported in the literature. Distinction becomes critical as IHW is harbinger of a complete AV block. This is the largest series and the first clinic-etiological profile of IHW patients published to date.
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Background Fulminant myocarditis can cause biventricular dysfunction with a mortality rate over 40%. We report a case with severe biventricular failure due to fulminant myocarditis that was successfully supported by left and right ventricular assist devices. Case A 65-year-old woman presented with chest pain, abdominal pain and diarrhea. She was hypotensive and labs revealed elevated troponin-T of 13.5 ng/mL and lactate of 4.3 mmol/L. She was positive for COVID by antigen testing. She was started on multiple vasopressor infusions and admitted to the intensive care unit. Echocardiogram revealed a severely reduced left ventricular ejection fraction of 15% and severe global hypokinesis. The following day, she developed a wide complex tachycardia that was refractory to amiodarone, lidocaine and multiple defibrillation attempts. She was transferred emergently to the cardiac cath lab where coronary angiography revealed an isolated 70% stenosis of the distal left circumflex artery. A Swan-Ganz catheter was placed that yielded a cardiac index by Fick of 1.2 L/min/m2, systemic vascular resistance of 1270 dynesseccm-5 and mixed venous oxygen saturation of 35%. Decision was made to emergently insert an Impella CP device. That evening, she developed complete heart block and transvenous pacing wire was inserted. Due to frequent suction alarms, decision was made to insert ProtekDuo device, which resulted in hemodynamic stabilization. A temporary coronary sinus pacing lead for atrial capture was inserted to improve atrioventricular synchrony. After several days of monitoring, repeat echocardiogram showed complete recovery of biventricular function and Impella CP and ProtekDuo devices were removed. Decision-making The decision of early implantation of ProtekDuo device was made to provide adequate blood flow to the left ventricular assist device for hemodynamic support. In addition, increased atrioventricular synchrony via insertion of temporary coronary sinus pacing wire improved cardiac output. Conclusion Fulminant myocarditis involving biventricular dysfunction can be supported by the use of simultaneous left and right ventricular assist devices.Copyright © 2023 American College of Cardiology Foundation
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Covid19 is still one of the major public health problems of all countries nowadays. The most common cardiac manifestations reported till now are acute coronary syndrome, myocarditis, and arrhythmia. The prevalence of COVID-19 induced arrhythmias is different in recent reports and varies from benign sinus tachycardia to more ominous cases of severe bradycardia or even malignant ventricular arrhythmias. Here in, we describe a case of complete heart block in severe covid-19 pneumonia and review all recent relevant case reports published to date in order to understand the probable mechanisms and contributing factors of this rare complication of the disease.Copyright © 2022, Isfahan University of Medical Sciences(IUMS). All rights reserved.
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Objectives: The study aims to determine the association between electrocardiographic abnormalities and in-hospital mortality of patients with Coronavirus Disease 2019 (COVID-19) infection admitted in a tertiary hospital in the Philippines. Material(s) and Method(s): We conducted a retrospective study of confirmed COVID-19-infected patients. Demographic, clinical characteristics, and clinical outcomes were extracted from the medical records. Electrocardiographic analysis was derived from the 12-lead electrocardiogram (ECG) recorded upon admission. The frequencies and distributions of various clinical characteristics were described, and the ECG abnormalities associated with in-hospital mortality were investigated. Result(s): A total of 163 patients were included in the study, most were female (52.7%) with a median age of 55 years old. Sinus rhythm (40%), nonspecific ST and T wave changes (35%), and sinus tachycardia (22%) were the frequently reported ECG findings. The presence of any ECG abnormality was detected in 78.5% of patients and it was significantly associated with in-hospital mortality (p = 0.038). The analysis revealed a statistically significant association between in-hospital mortality and having atrial fibrillation or flutter (p = 0.002), supraventricular tachycardia (SVT) (p = 0.011), ventricular tachycardia (p = 0.011), third-degree atrioventricular block (AVB) (p = 0.011), T wave inversion (p = 0.005) and right ventricular hypertrophy (RVH) (p = 0.011). Conclusion(s): The presence of any ECG abnormality in patients with COVID-19 infection was associated with in-hospital mortality. ECG abnormalities that were associated with mortality were atrial fibrillation or flutter, SVT, ventricular tachycardia, third-degree AVB, T wave inversion, and RVH. Supporting Documents Association of electrocardiographic abnormalities with in-hospital mortality in adult patients with COVID-19 infection TARRANZA, Jannah Lee [1];RAMIREZ, Marcellus Francis [1,2];YAMAMOTO, Milagros [1] 1 Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines 2 Division of Electrophysiology, Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines.
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Background Primary cardiac lymphoma (PCL) is an extranodal lymphoma involving only the heart and/or pericardium. PCL accounts for 2% of primary cardiac tumors and 0.5% of extranodal lymphomas. Its diagnosis is usually delayed due to rarity and non-specific findings. Case A 77-year-old man with Alzheimer dementia, atrial fibrillation on apixaban, and COVID-19 illness 3-weeks prior, who presented to the hospital with diffuse abdominal discomfort, fatigue, anorexia, and hypoactivity. Patient was tachycardic and normotensive with pronounced jugular venous distention, non-collapsing with respiration. ECG revealed sinus tachycardia, first degree atrioventricular (AV) block and chronic LBBB. Cardiac troponins were mildly elevated without significant delta. An abdominopelvic CT revealed an incidental, large pericardial effusion (PE). Bedside echocardiogram confirmed a large hemodynamically significant PE as well as a mass-like echogenicity encasing and infiltrating the pericardium and myocardium at the basal aspect of the right ventricle free wall. Decision-making In view of recent COVID-19 infection, he was started on indomethacin and colchicine for suspected viral or neoplastic pericarditis. Pericardiocentesis drained 900ml of amber to serosanguineous fluid with quick hemodynamic improvement. Fluid analysis was non-diagnostic for neoplasia. Subsequently, he developed symptomatic bradycardia with an intermittent complete AV block with junctional escape rhythm, transitioning to a second-degree AV block after removal of beta-blocker. Awaiting permanent pacemaker implant, he developed ventricular fibrillation with sudden cardiac death that required prolonged unsuccessful ACLS. Autopsy revealed an extensive infiltrative tumor, predominantly right-sided, consistent with primary cardiac B-cell lymphoma. Conclusion PCL should be part of the working diagnosis in patients presenting with a pericardial effusive process in combination with a right sided myocardial mass. Early cardiac MRI/PET scan or biopsy should be considered when the diagnosis is not certain. Prompt diagnosis could allow for treatment that potentially prolongs survival.Copyright © 2023 American College of Cardiology Foundation
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Case Report: Our patient is an 8-year-old Caucasian female with a history of choanal atresia, first degree heart block, recurrent urinary tract infections, and recent COVID-19 infection, who initially presented with an episode of syncope and vomiting. By history, she had two weeks of daily fever and an intermittent nonspecific rash. She was diagnosed with a UTI 5 days prior to presentation but had not defervesced despite treatment. Shewas initially found to be in shock with tachycardia and poor perfusion and was treated with fluid resuscitation, antipyretics, and empiric antibiotics. Labs were significant for leukopenia, elevated inflammatory markers, lactic acidosis, coagulopathy, and mildly elevated troponin. Chest x-ray showed abnormal but non-specific widespread infiltrates. She was initially treated with IVIG and pulse steroids for a working diagnosis of MIS-C, however she did not improve and a more extensive infectious, oncologic, and rheumatologic work-up was performed. Her workup revealed a disseminated Mycobacterium abscessus infection. Bone marrow biopsy revealed myelodysplasia with monosomy 7. Her buccal swab testing revealed a heterozygous germline mutation in the GATA2 gene, a variant that is predicted to cause loss of normal protein function. She is presently on multidrug regimen for her mycobacterial infection. Her myelodysplasia evolved into an acute leukemia, and she is undergoing chemotherapy for that at this time. Discussion(s): GATA2 deficiency, first identified in 2011, is a rare immune disorder resulting in a wide variety of clinical presentations. It is caused by a germline mutation of the GATA2 gene that disrupts blood cell differentiation, resulting in decreased or absent monocytes, B cells, NK cells, and dendritic cells1. This case presented multiple challenges due to the broad range of differential diagnoses. This patient was ultimately diagnosed with myelodysplastic syndrome associated with monosomy 7 and GATA2 deficiency, confirmed by FISH testing. Due to the presentation and lab derangements this patient had, there was a delay in targeted treatment while managing her cytopenias and presumed pulmonary infection. GATA2 deficiency carries a high risk of progression from myelodysplastic syndrome to acute myelogenous leukemia. The best long-term treatment for GATA2 deficiency is hematopoietic stem cell transplant, which is the ultimate goal for our patient. Copyright © 2023 Southern Society for Clinical Investigation.
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Although Legionnaires' disease mainly affects the lungs, it can also present with other systemic involvement, including rare cardiac manifestations. Recognised presentations are endocarditis, myocarditis, pericarditis, and pericardial effusion. A 72-year-old British man presented with a six-day history of dry cough and a four-day history of fever during the peak of the COVID-19 pandemic. His electrocardiogram showed Mobitz type II atrio-ventricular block. Although all the cultures were negative, the chest X-ray demonstrated COVID-19 infection-like features. With high clinical suspicions and chest X-ray features, the polymerase chain reaction of the COVID tests was repeated three times and all were negative. He had a positive urinary Legionella antigen, and his bradycardia and heart block improved after treatment with amoxicillin/clavulanic acid, and clarithromycin. As the electrocardiogram showed Mobitz type II, a permanent pacemaker was implanted. The follow-up pacemaker check showed that he still required active pacing.
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BACKGROUND: Coronavirus disease 2019 (COVID-19) may lead to myocardial damage and arrhythmia. Patients with ECG changes have shown an increased risk of mortality. OBJECTIVE(S): We aimed to study the changes in the electrocardiogram, which may be of great significance for risk stratification of COVID-19-positive patients. METHOD(S): A retrospective study was conducted to compare electrocardiogram changes and disease severity markers in COVID-19-positive patients admitted to a referral hospital between February 20 and March 20, 2020. RESULT(S): Our study consisted of 201 cases, including 123 males and 78 females. Ages ranged between 16 and 97 years old. Fifty-two (25.9%) cases had a history of ICU admission. Multivariate logistic regression analysis showed that a low O2 saturation level (OR = 0.920, 95% CI 0.868-0.976, p=0.005), several lab tests, ECG changes (OR = 46.84, 95% CI 3.876- 566.287, p =.002) and Age (OR = 1.03, 95% CI 1.000- 1.065, p =.048) were the independent risk factors for predicting mortality rate. In addition, we utilized multivariate logistic regression analysis, demonstrating that LBBB (OR = 4.601, 95% CI: 1.357-15.600, p=0.014) is the only ECG risk factor associated with morbidity in elderly patients with ECG changes. CONCLUSION(S): ECG changes are strong indicators of high mortality rates in elderly COVID-19 patients. ECG interpretations should therefore be used for risk stratification and predicting the need for ICU admission. Copyright © 2022, Isfahan University of Medical Sciences(IUMS). All rights reserved.
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Introduction: Complete heart block (CHB) in association with Covid-19 is uncommon and has been described primarily in the pre-vaccine time period. In the setting of acute Covid-19 infection, decision to treat CHB with permanent pacemaker (PPM) is often uncertain as the CHB may resolve or persist. We present a case of reversible CHB and Covid-19 infection in a vaccinated healthy 28- year-old. Case: A healthy 28-year-old female presented after syncope. She had been vaccinated three times against Covid-19 with Pfizer-BioNTech mRNA vaccine with her third dose four months prior. She had known Covid-19 exposure and developed sore throat three days prior to presenting with syncope. She had no other symptoms. Physical exam was remarkable only for bradycardia. Labs showed positive Covid-19 PCR test and elevated troponin of 0.396 ng/mL. Complete blood counts, metabolic panel, ESR and CRP were normal. Lyme IgM and IgG were negative by Western blot. ECG showed CHB with a rate of 35 beats per minute (Figure 1A). Echocardiogram showed no abnormalities. The patient remained in CHB for 24 hours, at which point PPM was implanted after shared-decision making. Post-PPM ECG showed AV-paced rhythm (Figure 1B). At follow up, PPM interrogation showed that she transitioned to sinus rhythm with right bundle branch block (RBBB) followed by a return to normal sinus rhythm without RBBB 5 days after implantation (Figure 1C). Cardiac MRI two months after PPM implantation showed no abnormalities. Discussion(s): This was a case of Covid-19 associated myocardial injury with CHB in a fullyvaccinated, healthy adult treated with PPM. Despite vaccination, this patient experienced myocardial and conduction system involvement during acute Covid-19 infection. Myocardial injury along with this ECG progression suggested that there was transient inflammation of the myocardial septum resulting in CHB. It may be reasonable to delay PPM implantation in cases of CHB and Covid-19 infection as the CHB may be transient.
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Introduction: This case identifies vagal tone as a paradoxical cause of coronary artery spasm, coinciding with complete heart block. It will additionally identify proper management in these cases. Clinical Presentation: A 53 year old male with a medical history of HIV not of ART, acute, infectious COVID-19 and late, latent syphilis admitted for malaise, found to have DLBCL. Following a routine blood draw the patient experienced acute chest and abdominal pain. Minutes later, while having a bowel movement he experienced syncope with heart rates in the 30s. EKG showed ST elevations in leads II, III, and aVF. Troponin-T was elevated to 0.15. Echocardiogram showed inferior wall hypokinesis. Coronary angiography showed non-obstructive right coronary disease. Cardiac MRI demonstrated no evidence of infiltrative disease or myocarditis. The patient experienced a similar episode the following morning, during blood draw, EKG and telemetry demonstrated complete heart block with ST elevations (image). This suggested vagal mediated AV block with coronary artery spasm (CAS). He was started on the anticholinergic hyoscyamine and amlodipine for vasodilation. Following initiation of therapy, the patient had no further episodes of chest pain or bradycardia. Discussion(s): While acetylcholine causes vasodilation via endothelial NO, interestingly, it can also lead to CAS. In the setting of vascular smooth muscle cell (VSMC) hyper-reactivity or high vagal tone, VSMC muscarinic receptors are activated leading to vasoconstriction. Vagal tone can cause both CAS with resulting STEMI as well as AV blockade resulting in high degree heart block (image). When ischemic symptoms are accompanied by AV block in the setting of high vagal tone, consider vagal mediated CAS. Calcium channel blockers such as amlodipine are used to manage CAS. When the suspected mechanism is vagal tone, management includes avoidance of precipitating factors and or anticholinergic premedication.
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INTRODUCTION: Dexmedetomidine is administrated in the ICU to treat adrenergic hyperactivity associated with alcohol withdrawal syndrome (AWS). Reduced ICU bed availability and drug shortages during the COVID-19 pandemic have spurred interest in mitigation strategies. The objective of this study was to develop preliminary data on the safety of dexmedetomidine when administered for AWS in nonintubated patients in order to develop a protocol for its use outside of the ICU. METHOD(S): Patients >=18 years of age admitted to an ICU for AWS and received dexmedetomidine between January 2020 and January 2022 were included. Patients were excluded if they required invasive mechanical ventilation or received dexmedetomidine for indications other than AWS. Bradycardia was defined as a heart rate < 40 beats per minute and hypotension as a systolic blood pressured < 80 mmHg. Heart block was identified using 12-lead electrocardiograms. Need for intervention for adverse drug effects was also recorded. Continuous data are reported as median (IQR) and nominal or categorical data as number (%). RESULT(S): Of the 204 patients screened, 148 (73%) were excluded for invasive mechanical ventilation and 8 (4%) for receipt of dexmedetomidine for non-AWS indications, leaving 48 (24%) evaluable patients. Most were male (n=36, 75%), white (n=43, 90%) and non-Hispanic/ Latino (n=47, 98%). Patients were bedded in the emergency department (n=20;42%), an intermediate care unit (n=11;23%), an outside hospital (n=10;21%), a general medical floor (n=6;12%), or perioperative unit (n=1, 2%) prior to ICU admission. The median initial dexmedetomidine dose was 0.35 (0.1, 0.5) mcg/kg/hr and the maximum dose was 1.2 (0.8, 1.4) mcg/ kg/hr. Time to the maximum dose was 2.2 (0.5, 8.5) hours and the total dexmedetomidine infusion duration was 25 (13, 40) hours. Hypotension occurred in 10 (21%) patients-only 2 (4%) required fluid administration, none received pressors or dose reduction. Bradycardia and heart block were not observed. CONCLUSION(S): Dexmedetomidine administration for AWS in non-intubated ICU patients was safely accomplished in 95% of patients with only 4% of the cohort developing hypotension requiring fluid administration. These results will be used to develop a protocol for dexmedetomidine administration in non-ICU areas for AWS.
ABSTRACT
An 81-years-old with a history of hypertension, dyslipidemia, and chronic ischemic heart disease with prior stent implantation of right coronary artery in 2011. Due to its poor compliance, no recurrent symptoms, and, finally, the COVID-19 pandemic, the patient did not perform any cardiological follow-up during these years. Unfortunately, the last six months he has reported the onset of dyspnea and typical angina due to moderate efforts, undervalued by the patient. Because of the rapid worsening of dyspnea and typical angina in the last 5 days, he went to the local emergency department (ED). The role in/role out routine exams performed in the ED documented a COVID-19 infection. At the ED, his vital signs were normal, with a blood pressure of 135/75 mm Hg, heart rate of 74 regular beats/min, body temperature of 36.5 degreeC, oxygen saturation of 97% in ambient air, and respiratory rate of 16/ min. Of note, the chest x-ray was normal, as well as no alterations were documented at the CTscan performed a few hours later. First-line blood sample tests were within range except for Hb 10 mg/dl. Therefore, a cardiological evaluation was requested. Electrocardiogram (ECG) showed inverted T-waves in V1-4 leads, and echocardiography showed normal left ventricular ejection fraction (FE 55% Simpson), left ventricular anterolateral wall hypokinesia, and severe aortic stenosis (V max 4.78 m/ s, Gr max 4.78 m/s, Gr medium 59 mmHg). Since myocardial necrosis enzymes were increased (T-hs 118.7 ng/dl;CK-MB 6.3 ng/L;NT-ProBNP 761 ng/dl), leading to the suspicion of acute coronary syndrome the patient underwent coronary angiography, showing critical stenoses of the left descending artery (LAD), circumflex (LCX), I obtuse marginal (IOM), and patent stent of the right coronary artery. Therefore, the Heart team deemed the patient at high operatory risk choosing, in agreement with the patient, for a percutaneous coronary intervention (PCI) followed by TAVR. Accordingly, the patients underwent PCI of LAD with the implantation of a Xience-Serra 3.0x15 mm and PCI of LCX with the implantation of an Onyx 2.75x18 mm stent. After COVID -19 resolution, which happen 7 days later, the patient was moved to our cardiology department. Two days later in the same procedure, we performed the first PCI of I-OM with the implantation of a Xience Sierra 3.0x18 mm stent following a TAVI with the implantation of Evolute Pro valve 29 mm. The postprocedure echocardiogram showed an optimal valve position with a transvalvular mean pressure gradient of 4 mm Hg. After six days post-TAVI, for a complete atrioventricular block, the patient also underwent a pacemaker implantation. The patient was finally discharged after 10 from TAVI. Discussion(s): This case report offers several foods for thought. First, the COVID-19 pandemic has negatively affected primary and secondary prevention, even for patients affected by cardiovascular disease. Our patient has postponed clinical checks even when the symptoms reappeared, also because of the concerns lead by the COVID-19 pandemic. Second, completeness and timing of coronary disease revascularization, which in this case was staged and performed before TAVI. Finally, the late occurrence of advanced heart block requiring PM implantation. For instance, in an era of fast-track TAVI, more studies are warranted to identify patients who are at higher risk of late PM implantation.
ABSTRACT
Background: Wenckebach periodicity has classically been considered an AV nodal phenomenon. Infra-Hisian Wenckebach (IHW) scarcely reported in the literature. The distinction, sometimes, becomes critical as IHW is a harbinger of complete AV block and demands permanent pacing contrary to AV nodal Wenckebach. We aimed too study clinico-electrophysiological profile of patients with Infrahisian Wenckebach (IHW) conduction. Method(s): Patients with a clinical diagnosis of atrioventricular (AV) block (excluding complete Heart Block) who underwent permanent pacemaker implantation(PPI) based on standard indications from July 2021-June 2022 at The Madras Medical Mission were prospectively subjected to pre- implant Electrophysiology study to document conduction pathology Results: A total of 94 patients underwent PPI for symptomatic AV block during the study period. EPS was performed in all but one patient (COVID pneumonia). Incidence of IHW was 9/93(9.6%) of patients with AV block. Suprahisian wneckebach was noted in 8/93 patients. There is no gender predisposition (M-4, F-5) and their mean age was 71.4+11.7 years. As many as half of the patients (5/9) had an underlying narrow QRS. The mean QRS duration was 130 + 19.3. Ischemic heart disease affected half of the patients and cardiomyopathy in 4/9 patients (mean EF 45.1+13.7%). Presentation was syncope in all and mean NYHA class was 2.1. Presentation ranged from isolated 1st degree AV block (1/9) to tri-fascicular block (3/9). At EP study, mean basal HV interval was 94.7+27.1ms. IHW was noted spontaneously in 4 patients and on atrial pacing in the remaining. Mean PR interval of the first beat of the Wenckebach cycle was 223 + 14.5 ms. Mean increment in PR interval from the first to the 2nd beat of the cycle was found to be minimal (14.1 + 6.7 ms) which was significantly less when compared to that in patients with suprahisian Wenckebach (44.1 + 10.8 ms), p=0.03). All patients received conduction system pacing implant. In the literature, a total of 11 documented cases have been reports (8 case reports). Ours is the largest case series and first to study the clinical profile of such patients. Conclusion(s): Wenckebach periodicity is classically considered an AV nodal phenomenon. IHW scarcely reported in literature. Distinction becomes critical as IHW is harbinger of complete AV block. However, the prevalence as reported in the current study may not be so less as previously reported, especially with the advent of conduction system pacing where EPS is routinely performed to localize the level of AV block. This is the largest series and first clinic-etiological profile of IHW patients published till date. [Formula presented] Copyright © 2022