Ventricular Fibrillation in an Afebrile COVID-19 Patient Presenting With Transient Type-I Brugada Pattern.

COVID-19 has been associated with an increased risk of both atrial and ventricular arrhythmias. Brugada syndrome (BrS), an inherited sodium channelopathy presenting with a characteristic ECG morphology, confers a baseline risk of ventricular arrhythmias such as ventricular fibrillation (VF), especially during febrile illnesses. However, mimics of BrS, termed Brugada phenocopies (BrP), have been noted in association with fever, electrolyte abnormalities, and toxidromes outside of viral illness. Such presentations manifest the same ECG pattern, the type-I Brugada pattern (type-I BP). Thus, the acute stage of an illness such as COVID-19, when accompanied by a first-time presentation of type-I BP, may not result in a certain diagnosis of BrS versus BrP. Thus, expert recommendations are to anticipate arrhythmia regardless of the presumed diagnosis. Here we demonstrate the importance of these guidelines and a novel report of VF in the setting of a transient type-I BP in afebrile COVID-19. We discuss the potential factors which may have triggered VF, the presentation of isolated "coved" ST elevation in V1, and the difficulty of BrS versus BrP diagnosis in acute illness. In summary, a SARS-CoV-2 positive 65-year-old male without significant cardiac history for BrS presented with type-I BP after two days of shortness of breath. Hypoxemia, hyperkalemia, hyperglycemia, elevated inflammatory markers, and acute kidney injury were present. After treatment, his ECG normalized; however, aborted VF occurred days later while afebrile and normokalemic. Follow-up ECG again revealed a type-I BP, which also became more apparent during an episode of bradycardia, a classic finding in BrS. This case suggests that there is room for larger studies to determine the prevalence and outcomes when type-I BP presents in acute COVID-19. When possible, genetic data should be obtained to confirm BrS, a notable limitation in our case. Regardless, it corroborates guideline-directed clinical management, with heightened vigilance for arrhythmia in such patients until full recovery.

Prediction and Analysis of Heart Diseases Using Heterogeneous Computing Platform

The work in this paper helps study cardiac rhythms and the electrical activity of the heart for two of the most critical cardiac arrhythmias. Various consumer devices exist, but implementation of an appropriate device at a certain position on the body at a certain pressure point containing an enormous number of blood vessels and developing filtering techniques for the most accurate signal extraction from the heart is a challenging task. In this paper, we provide evidence of prediction and analysis of Atrial Fibrillation (AF) and Ventricular Fibrillation (VF). Long-term monitoring of diseases such as AF and VF occurrences is very important, as these will lead to occurrence of ischemic stroke, cardiac arrest and complete heart failure. The AF and VF signal classification accuracy are much higher when processed on a Graphics Processor Unit (GPU) than Central Processing Unit (CPU) or traditional Holter machines. The classifier COMMA-Z filter is applied to the highly-sensitive industry certified Bio PPG sensor placed at the earlobe and computed on GPU.

Amplitude Spectrum Area of ventricular fibrillation to guide defibrillation: a small open-label, pseudo-randomized controlled multicenter trial.

BACKGROUND: Ventricular fibrillation (VF) waveform analysis has been proposed as a potential non-invasive guide to optimize timing of defibrillation. METHODS: The AMplitude Spectrum Area (AMSA) trial is an open-label, multicenter randomized controlled study reporting the first in-human use of AMSA analysis in out-of-hospital cardiac arrest (OHCA). The primary efficacy endpoint was the termination of VF for an AMSA ≥ 15.5 mV-Hz. Adult shockable OHCAs randomly received either an AMSA-guided cardiopulmonary resuscitation (CPR) or a standard-CPR. Randomization and allocation to trial group were carried out centrally. In the AMSA-guided CPR, an initial AMSA ≥ 15.5 mV-Hz prompted for immediate defibrillation, while lower values favored chest compression (CC). After completion of the first 2-min CPR cycle, an AMSA < 6.5 mV-Hz deferred defibrillation in favor of an additional 2-min CPR cycle. AMSA was measured and displayed in real-time during CC pauses for ventilation with a modified defibrillator. FINDINGS: The trial was early discontinued for low recruitment due to the COVID-19 pandemics. A total of 31 patients were recruited in 3 Italian cities, 19 in AMSA-CPR and 12 in standard-CPR, and included in the data analysis. No difference in primary outcome was observed between the two groups. Termination of VF occurred in 74% of patients in the AMSA-CPR compared to 75% in the standard CPR (OR 0.93 [95% CI 0.18-4.90]). No adverse events were reported. INTERPRETATION: AMSA was used prospectively in human patients during ongoing CPR. In this small trial, an AMSA-guided defibrillation provided no evidence of an improvement in termination of VF. TRIAL REGISTRATION: NCT03237910. FUNDING: European Commission - Horizon 2020; ZOLL Medical Corp., Chelmsford, USA (unrestricted grant); Italian Ministry of Health - Current research IRCCS.

Takotsubo Syndrome and Sudden Cardiac Death.

Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4-5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.

Syncope after COVID-19 Vaccination in a Young Man with Unmasking Brugada Syndrome.

A 23-year-old man with no significant medical history was rushed to a hospital due to transient loss of consciousness with incontinence. The patient had developed a fever after his second dose of coronavirus disease 2019 (COVID-19) vaccine, and the patient was found groaning in bed approximately 40 hours after the vaccination in the early morning. The patient was diagnosed with Brugada syndrome (BrS) based on a drug-provocation test. His father had been diagnosed with BrS and died suddenly at 51 years of age. Young adults with a family history of BrS should be cautioned about fever following COVID-19 vaccination.

COVID-19 Vaccination-Induced Ventricular Fibrillation in an Afebrile Patient With Brugada Syndrome.

A 43-year-old man presented with cardiac arrest 2 days after the second coronavirus disease 2019 (COVID-19) vaccination with an mRNA vaccine. Electrocardiograms showed ventricular fibrillation and type 1 Brugada pattern ST segment elevation. The patient reported having no symptoms, including febrile sensation. There were no known underlying cardiac diseases to explain such electrocardiographic abnormalities. ST segment elevation completely disappeared in two weeks. Although there were no genetic mutations or personal or family history typical of Brugada syndrome, flecainide administration induced type 1 Brugada pattern ST segment elevation. This case suggests that COVID-19 vaccination may induce cardiac ion channel dysfunction and cause life threatening ventricular arrhythmias in specific patients with Brugada syndrome.

A case of refractory ventricular fibrillation after caffeine poisoning successfully treated by supportive care.

Caffeine (1,3,7-trimethylxantine), a structural analog of adenosine, is widely used as a central nervous system stimulant in beverages and drugs. Caffeine overdose induces hypokalemia, fatal ventricular fibrillation, and cardiac arrest, resulting in death. We describe a case of caffeine overdose that presented with refractory ventricular fibrillation that was treated with supportive care because invasive care for severely ill patients was limited due to the COVID-19 pandemic. A 20-year-old woman with no underlying medical history ingested 90,200-mg caffeine tablets (total dose 18 g) in a suicide attempt. She was transported to the emergency department 45 min after ingestion with dizziness, palpitations, nausea, and vomiting. She developed cardiac arrest 80 min after ingesting the caffeine, with refractory ventricular tachycardia that recurred for about 2.5 h. Advanced life support including defibrillation was started immediately and we gave intravenous Intralipid emulsion, potassium chloride, amiodarone, and esmolol, without hemodialysis or extracorporeal membrane oxygenation (ECMO). The ventricular fibrillation was stopped 4 h after ingestion. As supportive care, mechanical ventilation, sedatives, and neuromuscular blockade were continued until 12 h after ingestion. Although she suffered from prolonged, refractory ventricular tachycardia, she recovered without complications. This case report describes the clinical course of severe caffeine intoxication without an active elimination method, such as hemodialysis or ECMO and explores the treatment of caffeine intoxication with a literature review.

Clinical outcomes among out-of-hospital cardiac arrest patients treated by extracorporeal cardiopulmonary resuscitation: The CRITICAL study in Osaka.

AIM: Extracorporeal cardiopulmonary resuscitation (ECPR) is performed in refractory out-of-hospital cardiac arrest (OHCA) patients, and the eligibility has been conventionally determined based on three criteria (initial cardiac rhythm, time to hospital arrival within 45 minutes, and age <75 years) in Japan. Owing to limited information, this study descriptively determined neurological outcomes after applying the three criteria among OHCA patients who underwent ECPR. METHODS: This study conducted a post-hoc analysis of data from the Comprehensive Registry of Intensive Care for OHCA Survival (CRITICAL) study. This was a multi-institutional prospective observational study of OHCA patients in Osaka Prefecture, Japan. All adult (aged ≥18 years) OHCA patients with internal medical causes treated with ECPR between 1 July 2012 and 31 December 2019 were evaluated. We described one-month neurological favourable outcomes based on the three criteria (initial shockable, time to hospital arrival within 45 minutes, and age <75 years), and we compared them using the chi-square test. RESULTS: Among 18,379 patients screened from the CRITICAL study database, we included 517 OHCA patients treated by ECPR; 311 (60.2%) patients met all three criteria. Favourable neurological outcomes were as follows: patients meeting no or one criterion: 2.3% (1/43), those meeting two criteria: 8% (13/163), and those meeting all criteria: 16.1% (50/311) (P-value = 0.004). CONCLUSIONS: In this study, approximately 60% of patients treated by ECPR met the three criteria (initial shockable, time to hospital arrival within 45 minutes, and age <75 years), and the greater the number of criteria met, the better were the neurological outcomes achieved.

Arrhythmia in COVID-19.

The current outbreak of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) also known as coronavirus disease 2019 (COVID-19) has quickly progressed to a global pandemic. There are well-documented cardiac complications of COVID-19 in patients with and without prior cardiovascular disease. The cardiac complications include myocarditis, heart failure, and acute coronary syndrome resulting from coronary artery thrombosis or SARS-CoV-2-related plaque ruptures. There is growing evidence showing that arrhythmias are also one of the major complications. Myocardial inflammation caused by viral infection leads to electrophysiological and structural remodeling as a possible mechanism for arrhythmia. This could also be the mechanism through which SARS-CoV-2 leads to different arrhythmias. In this review article, we discuss arrhythmia manifestations in COVID-19.

Ventricular fibrillation arrest due to Brugada syndrome in a coronavirus disease 2019 patient with negative procainamide challenge: a case report.

BACKGROUND: Pharmacologic challenge test is often used to diagnose Brugada syndrome (BrS) when spontaneous electrocardiograms (ECG) do not show type I Brugada pattern but reported sensitivity varies. The role of the exercise stress test in diagnosing Brugada syndrome is not well-established. CASE SUMMARY: A patient had a type I Brugada pattern ECG during the recovery phase of exercise stress test but had a negative procainamide challenge test. He had a loop recorder implanted and later survived a ventricular fibrillation (VF) arrest provoked by coronavirus disease 2019 (COVID-19). Electrocardiogram on arrival showed type 1 Brugada pattern. He was discharged after implantable cardioverter-defibrillator implantation. He later underwent genetic testing and was found to be heterozygous for c.844C>G (p.Arg282Gly) mutation in the SCN5A gene. DISCUSSION: Type 1 Brugada pattern ECG may be unmasked by ST-segment augmentation during recovery from exercise. Exercise stress test may play a role in the diagnosis of Brugada syndrome when suspicion for Brugada syndrome remains after a negative procainamide challenge test or if the patient has exercise-related symptoms. COVID-19 can unmask BrS and trigger a VF cardiac arrest.

Acquired Long QT and Ventricular Arrhythmias in the Setting of Acute Inflammation: A Case Series.

We report a case series of 4 patients with transient marked QTc prolongation and ventricular arrhythmias in the setting of inflammation with very high ferritin levels. Three patients were positive for coronavirus disease-2019. In the setting of an acute rise in inflammatory markers, electrocardiography screening for QTc prolongation is warranted. (Level of Difficulty: Beginner.).

A Case of Ventricular Fibrillation in Asymptomatic COVID-19.

In this report, we present a case of ventricular fibrillation (VF) arrest in an asymptomatic coronavirus disease 2019 (COVID-19) patient with no cardiac history and normal cardiac workup. Cardiac involvement in COVID-19 has been described previously in hospitalized patients with severe COVID-19. To our knowledge, this is the first report to describe VF arrest in a patient who was incidentally found to have COVID-19.

The Role of the Automated Implantable Cardioverter Defibrillator (AICD) for Secondary Prevention in the COVID-19 Era.

Life-threatening arrhythmias have been variably reported among patients hospitalized for COVID-19 infection. Sudden cardiac arrest (SCA) in COVID-19 patients is an alarming concern for clinicians. Multiple factors play an important role in the development of SCA in patients with severe systemic illness. We describe a case of COVID-19 in a New York City hospital in Spring 2020 that rapidly developed SCA and, before discharge, received a single lead transvenous implantable cardioverter defibrillator for secondary prevention. This case highlights the use of an automated implantable cardioverter-defibrillator as a secondary preventive measure irrespective of left ventricular function as a means of preventing recurrence of SCA as a sequela of COVID-19.

Ventricular arrhythmia burden during the coronavirus disease 2019 (COVID-19) pandemic.

AIMS: Our objective was to determine the ventricular arrhythmia burden in implantable cardioverter-defibrillator (ICD) patients during COVID-19. METHODS AND RESULTS: In this multicentre, observational, cohort study over a 100-day period during the COVID-19 pandemic in the USA, we assessed ventricular arrhythmias in ICD patients from 20 centres in 13 states, via remote monitoring. Comparison was via a 100-day control period (late 2019) and seasonal control period (early 2019). The primary outcome was the impact of COVID-19 on ventricular arrhythmia burden. The secondary outcome was correlation with COVID-19 incidence. During the COVID-19 period, 5963 ICD patients underwent remote monitoring, with 16 942 episodes of treated ventricular arrhythmias (2.8 events per 100 patient-days). Ventricular arrhythmia burden progressively declined during COVID-19 (P < 0.001). The proportion of patients with ventricular arrhythmias amongst the high COVID-19 incidence states was significantly reduced compared with those in low incidence states [odds ratio 0.61, 95% confidence interval (CI) 0.54-0.69, P < 0.001]. Comparing patients remotely monitored during both COVID-19 and control periods (n = 2458), significantly fewer ventricular arrhythmias occurred during COVID-19 [incident rate ratio (IRR) 0.68, 95% CI 0.58-0.79, P < 0.001]. This difference persisted when comparing the 1719 patients monitored during both the COVID-19 and seasonal control periods (IRR 0.69, 95% CI 0.56-0.85, P < 0.001). CONCLUSIONS: During COVID-19, there was a 32% reduction in ventricular arrhythmias needing device therapies, coinciding with measures of social isolation. There was a 39% reduction in the proportion of patients with ventricular arrhythmias in states with higher COVID-19 incidence. These findings highlight the potential role of real-life stressors in ventricular arrhythmia burden in individuals with ICDs. TRIAL REGISTRATION: Australian New Zealand Clinical Trial Registry; URL: https://www.anzctr.org.au/; Unique Identifier: ACTRN12620000641998.

Malignant Arrhythmias in Patients With COVID-19: Incidence, Mechanisms, and Outcomes.

BACKGROUND: Patients with coronavirus disease 2019 (COVID-19) who develop cardiac injury are reported to experience higher rates of malignant cardiac arrhythmias. However, little is known about these arrhythmias-their frequency, the underlying mechanisms, and their impact on mortality. METHODS: We extracted data from a registry (NCT04358029) regarding consecutive inpatients with confirmed COVID-19 who were receiving continuous telemetric ECG monitoring and had a definitive disposition of hospital discharge or death. Between patients who died versus discharged, we compared a primary composite end point of cardiac arrest from ventricular tachycardia/fibrillation or bradyarrhythmias such as atrioventricular block. RESULTS: Among 800 patients with COVID-19 at Mount Sinai Hospital with definitive dispositions, 140 patients had telemetric monitoring, and either died (52) or were discharged (88). The median (interquartile range) age was 61 years (48-74); 73% men; and ethnicity was White in 34%. Comorbidities included hypertension in 61%, coronary artery disease in 25%, ventricular arrhythmia history in 1.4%, and no significant comorbidities in 16%. Compared with discharged patients, those who died had elevated peak troponin I levels (0.27 versus 0.02 ng/mL) and more primary end point events (17% versus 4%, P=0.01)-a difference driven by tachyarrhythmias. Fatal tachyarrhythmias invariably occurred in the presence of severe metabolic imbalance, while atrioventricular block was largely an independent primary event. CONCLUSIONS: Hospitalized patients with COVID-19 who die experience malignant cardiac arrhythmias more often than those surviving to discharge. However, these events represent a minority of cardiovascular deaths, and ventricular tachyarrhythmias are mainly associated with severe metabolic derangement. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT04358029.

Sudden Cardiac Arrest at the Triage of Emergency Medicine Department in a Patient With COVID-19.

A pneumonia outbreak with an unknown microbial etiology was reported in Wuhan, Hubei province of China, on December 31, 2019. This was later attributed to a novel coronavirus, currently called as severe acute respiratory system coronavirus 2 (SARS-CoV-2). Coronavirus disease 2019 (COVID-19) mainly affects the respiratory system and can also cause acute or chronic damage to the cardiovascular system. We present a case of a 64-year-old female with past medical history of diabetes mellitus and hypertension who presented to the Emergency Medicine Department with shortness of breath and worsening chest discomfort, then had a ventricular fibrillation (VF) arrest while in triage, in the context of COVID-19 diagnosis. Cardiovascular complications during the COVID-19 pandemic should be brought to medical attention; it is crucial that physicians be aware of the complications and treat it as an emergency.

Ventricular fibrillation and Takotsubo cardiomyopathy triggered by media panic on COVID-19: A case report.

Takotsubo cardiomyopathy has potentially lethal complications and can be caused by a media-induced diffuse atmosphere of life threatening and panic in preconditioned patients.

Clinical characteristics and outcomes of in-hospital cardiac arrest among patients with and without COVID-19.

AIMS: To define outcomes of patients with COVID-19 compared to patients without COVID-19 suffering in-hospital cardiac arrest (IHCA). MATERIALS AND METHODS: We performed a single-center retrospective study of IHCA cases. Patients with COVID-19 were compared to consecutive patients without COVID-19 from the prior year. Return of spontaneous circulation (ROSC), 30-day survival, and cerebral performance category (CPC) at 30-days were assessed. RESULTS: Fifty-five patients with COVID-19 suffering IHCA were identified and compared to 55 consecutive IHCA patients in 2019. The COVID-19 cohort was more likely to require vasoactive agents (67.3% v 32.7%, p = 0.001), invasive mechanical ventilation (76.4% v 23.6%, p < 0.001), renal replacement therapy (18.2% v 3.6%, p = 0.029) and intensive care unit care (83.6% v 50.9%, p = 0.001) prior to IHCA. Patients with COVID-19 had shorter CPR duration (10 min v 22 min, p = 0.002). ROSC (38.2% v 49.1%, p = 0.336) and 30-day survival (20% v 32.7%, p = 0.194) did not differ. A 30-day cerebral performance category of 1 or 2 was more common among non-COVID patients (27.3% v 9.1%, p = 0.048). CONCLUSIONS: Return of spontaneous circulation and 30-day survival were similar between IHCA patients with and without COVID-19. Compared to previously published data, we report greater ROSC and 30-day survival after IHCA in COVID-19.