ST-SEGMENT-ELEVATION MYOCARDIAL INFARCTION in COVID-19

Introduction: The Severe Acute Respiratory Syndrome Coronavirus-2 have been associated with cardiovascular adverse events including acute myocardial infarction due to a prothrombotic and hypercoagulable status, and endothelial dysfunction. Case report: We report the case of a 62-year-old women, admitted to the hospital via the emergency room for acute chest pain and dyspnea. A nasopharyngeal swab was positive for COVID19 real-time reverse transcriptase-polymerase chain reaction 11 day ago. On admission, she was hypotensive with systolic blood pressure measering 87 mmHg and tachycardic with 117 beats/min, oxygen saturation (SO2) was 94%. An 18-lead ECG revealed an infero-postero-lateral ST-elevation myocardial infarction with right ventricular involvement and a seconddegree- Mobitz Type 1 atrioventricular block. The coronary angiography from the right femoral artery showed acute thrombotic occlusion of the first diagonal branch with TIMI 0 flow and acute thrombotic occlusion of proximal right coronary artery with TIMI 0 flow. The most likely diagnosis was myocardial infarction secondary to a non-atherosclerotic coronary occlusion. The angioplasy was performed with dilatations with a semi compliant balloon, bailout implant of BMS, manual thrombus aspiration and intracoronary injection of tirofiban in the right coronary artery. The myocardial revascularization was ineffective. The patient developed significant severe hemodynamic instability and cardiac arrest for pulseless electric activity after 24 hours. Conclusion(s): The COVID-19 outbreak implies deep changes in the clinical profile and therapeutic management of STEMI patients who underwent PCI. At present, the natural history of coronary embolism is not well understood;however, the cardiac mortality rate are hight. This suggests these patients require further study to identify the natural history of the condition and to optimize management to improve outcome.

Complications Of A Severe Case Of Multisystem Inflammatory Syndrome In Children

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.

Atrio-Ventricular Conduction Abnormalities in Multisystem Inflammatory Syndrome in Children

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).

In-hospital outcomes of ST elevation myocardial infarction in post-COVID-19 patients.

Aim. To study clinical and anamnestic data, as well as inhospital outcomes in patients with ST elevation myocardial infarction (STEMI) with prior coronavirus disease 2019 (COVID-19) compared with previously uninfected STEMI patients. Material and methods. This prospective study included 181 patients treated for STEMI. The patients were divided into 2 groups, depending on the anti-SARS-CoV-2 IgG titer as follows: the main group included 62 seropositive patients, while the control group - 119 seronegative patients without prior COVID-19. Anamnesis, clinical and paraclinical examination, including electrocardiography, echocardiography, coronary angiography, were performed. Mortality and incidence of STEMI complications at the hospital stage were analyzed. Results. The mean age of the patients was 62,6+/-12,3 years. The vast majority were men (69,1% (n=125)). The median time from the onset of COVID-19 manifestations to STEMI was 60,00 [45,00;83,00] days. According to, the patients of both groups were comparable the severity of circulatory failure (p>0,05). Coronary angiography found that in patients of the main group, Thrombolysis In Myocardial Infarction (TIMI) score of 0-1 in the infarct-related artery was recorded much less frequently (62,9% (n=39) vs, 77,3% (n=92), p=0,0397). Patients of the main group demonstrated a lower concentration of leukocytes (9,30*109/l [7,80;11,40] vs 10,70*109/l [8,40;14,00], p=0,0065), higher levels of C-reactive protein (21,5 mg/L [9,1;55,8] vs 10,2 mg/L [5,1;20,5], p=0,0002) and troponin I (9,6 ng/mL [2,2;26,0] vs 7,6 ng/mL [2,2;11,5], p=0,0486). Lethal outcome was recorded in 6,5% (n=4) of cases in the main group and 8,4% (n=10) in the control group (p=0,6409). Both groups were comparable in terms of the incidence of complications (recurrent myocardial infarction, ventricular fibrillation, complete atrioventricular block, stroke, gastrointestinal bleeding) during hospitalization (p>0,05). Conclusion. Patients with STEMI after COVID-19, despite a more burdened history and higher levels of C-reactive protein and troponin I, compared with STEMI patients without COVID-19, did not differ significantly in clinical status, morbidity, and inhospital mortality.Copyright © 2023, Silicea-Poligraf. All rights reserved.

Pseudo-V1 ECG lead recording with quality smartwatches and medical interpretation may be necessary for timely and accurate remote detection of atrial flutter/fibrillation

Background: Remote rhythm monitoring with wearable devices is increasingly used especially for early detection of atrial fibrillation/flutter (AF/Afl), being the access to hospital discouraged, especially for frail elderly patients, due to the burden and risk of COVID-19 pandemic. Whereas devices using photo plethysmography (PPG) may misinterpret as AF pulse irregularities due to extrasystoles, patient-directed recording of a single (usually wrist-to-wrist) lead ECG (LEAD I) with hand-held devices or smartwatches have been developed to increase accuracy in AF detection. However, although recent studies validating such devices single-lead ECG recording have shown high sensitivity and specificity, false negative findings such as those reported here are still possible and must be prevented [1]. Purpose(s): Given previous experience of diagnostic uncertainty or failure of the smartwatch ECG (SW-ECG) LEAD I to detect AF/Afl, we have tested if false negative diagnosis could be avoided by recording in addition at least one right precordial (pseudo-V1) lead analyzed by a trained healthcare professional. Method(s): Over one calendar year observation, five patients with previous history of ablated supraventricular arrhythmias suffering sudden palpitations suspected of paroxysmal AF/Afl were instructed to record with their smartwatch at least one precordial lead in addition to LEAD I, to monitor ECG until the termination of symptoms. The SW-ECG strips were sent by telephone for professional interpretation. Diagnostic accuracy based on LEAD I and pseudo-V1 were independently validated by two cardiologists (diagnostic goldstandard - DGS). Result(s): 22 AF/Afl events occurred. Pharmacological cardioversion to sinus rhythm (SR) was obtained in 64%. 192 ECG strips were transmitted. 43,7% of the strips were automatically classified as not significant (or not valid ). Compared to DGS, out of 108 valid strips, correct automatic identification of AF/Afl was obtained in 36,4% with LEAD I, in 33,3% with pseudo V1 and in 54,5% with combined leads, respectively. Interestingly, the SW algorithm has wrongly diagnosed as SR, not only LEAD I, but also 39,4% of pseudo-V1 strips, despite clear-cut evidence of typical flutter waves (Figure 1), when RR intervals were regular due to high degree (e.g., 4:1) A-V block. Conclusion(s): With simple instructions, patients (or their relatives) can easily record an additional precordial (pseudo-V1) SW-ECG lead, that may enhance sensitivity and specificity for remote detection of AF/Afl. However, at present, visual interpretation of SW-ECG by a trained healthcare professional is still needed to guarantee 100% correct diagnosis of AF/Afl, crucial to reduce thromboembolic risk and timely initiate the appropriate treatments. The automatic interpretation of SW's ECG could be improved by appropriate training of a machine learning approach to detect and analyze the atrial waveform provided by an additional pseudo-V1 lead.

Complete Atrioventricular Block in COVID-19-Related Myocarditis: A Case Report

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.

Medium term survival in patients over ninety years-old undergoing pacemaker implantation

Background: According to the Italian National Statistical Institute, the 12- month probability of survival in the general population between 90 and 94 years-old is 26%. Pacemaker (PM) implantation is often an urgent and necessary intervention, but in these patients the benefit in terms of quality and duration of life is unclear. Purpose(s): To analyze characteristics, outcome and factors associated with survival in patients who had turned 90 at the time of PM implant. Method(s): All the PM implants performed in patients >=90 from 1/1/2019 to 12/31/2020 were analyzed. Clinical parameters, device characteristics and follow-up data were extrapolated from the SuitEstensa Ebit reporting system;the exitus was verified by analyzing data from the Regional Health System. Result(s): During the study interval, among the 554 patients undergoing PM implantation in our Center, 69 (12%) were >=90 years-old (mean age 92+/-2 years, 46% male;complete/advanced AV block in 76%). Twenty-six (38%) patients had history of atrial fibrillation and 19 (28%) ischemic heart disease. A cardiological co-morbidity (excluding AF) was present in 23 patients (33%). Oncological, pneumological and neurological comorbidities were present in 12 (18%), 19 (28%) and 32 (46%) respectively. Renal impairment was present in 25 patients (36%). In 47 patients (68%) there were at least 2 co-morbidities. After implantation (single-chamber in 36, dualchamber in 25 and VDD single-lead dual-chamber in 8 patients) complications occurred in 3 patients (2 pneumothorax and 1 lead dislodgment). Remote monitoring was activated in 57 patients (83%). Within August 31st 2021 (mean follow-up 288+/-193 days) 24 patients died (35%, 219+/-241 days after implant). Five patients (19% of patients implanted in 2019) died within 12 months. No patients died for device malfunction. Three patients died because of COVID-19 pneumonia. Renal dysfunction (Hazard Ratio-HR 8.05, p=0.002) and the presence of 2 or more co-morbidities (HR 6.03;p=0.015) were associated with a higher risk of death at univariate analysis;other significant variables were diabetes (HR 2.34;p=0.038), left ventricular ejection fraction (LVEF) (HR 0.70 for 5% variation;p=0.005), walking impairment (HR 2.99, p=0.006), the presence of oncological (HR 2.21;p=0.003), pneumological (HR 2.55;p=0.024) and neurological (HR 1.90, p=0.007) comorbidities. At multivariable analysis the only significant parameter associated with survival was LVEF (0.76 for 5% difference;p=0.043) Conclusion(s): At our Center, patients >=90 years-old undergo PM implantation mainly for advanced AVB. The good survival in the medium term, even better than expected in the general population, does not justify a too conservative attitude especially, but exclusively, in patients with less comorbidities.

Arrhythmia burden in COVID-19 patients from industrial workforce evaluated by remote patient monitoring technology

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.

Intra-hospital complications during SARS-CoV2 infection

Introduction: The SARS-CoV2 virus has a respiratory tropism. Although pulmonary complications are most often in the foreground, other complications affecting other organs have been observed and associated with a greater bad prognosis. The aim of this work was to report the various complications observed in patients hospitalized with COVID-19 pneumonia. Method(s): We carried out a retrospective study from the records of patients treated for pneumonia COVID-19 hospitalized between March 2020 and July 2021. Result(s): We collected 578 patients aged between 18 and 98 years old. Thoracic complications were dominated by bronchial superinfection(4.3%), pericarditis(3.3%), pneumomediastinum(1.2%) and pneumothorax(0.8%). Among the thromboembolic complications, we counted 30 pulmonary embolisms(5.2%), 7 acute limb ischemia (1.2%), 2 strokes(0.3%) and 1 venous thrombosis deep(0.1%). Cardiac arrhythmias were observed in 6% of cases. Bradycardia sinusitis was observed in 14 patients (2.4%) and first degree atrioventricular block in 4 patients (0.7%). Acute heart failure occurred in 31 patients (5.3%). Neurological disorders were observed in 23 patients with agitation (4%) and hallucinations (1%). Acute renal failure was the most common metabolic complication (20%) followed by rhabdomyolysis (28%) and cytolysis hepatic (36%). Two patients presented with diabetic ketoacidosis (0.3%). Complications cardiac, neurological and renal were associated with a worse prognosis (p=0.001) and the pulmonary complications with longer hospitalization (p=0.01). Conclusion(s): SARS-CoV2 infection is a polymorphic disease. Identification of the different complications respiratory and extra respiratory is essential for rapid multidisciplinary care.

A study of clinical and electrophysiological characteristics of Infrahisian Wenckebach

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.

Electrocardiographic predictors of disease severity, mortality, and advanced ventilatory support among hospitalized covid-19 patients: a two year single center retrospective, cohort study

Introduction: For detecting myocardial injury in severe and critical COVID-19, the electrocardiogram (ECG) is neither sensitive nor specific;but in a resource-poor environment, it remains relevant. Changes in the ECG can be a potential marker of severe and critical COVID-19 to be used for predicting not only disease severity but also the prognosis for recovery. Method(s): The admitting and interval ECGs of 1,333 COVID-19 patients were reviewed in a two-year, single-center, retrospective cohort study. Each was evaluated for 29 pre-defined ECG patterns under the categories of rhythm, rate, McGinn-White and RV overload patterns, axis and QRS abnormalities, ischemia/infarct patterns, and AV blocks before univariate and multivariate regression analyses for correlation with disease severity;need for advanced ventilatory support;and in-hospital mortality. Result(s): Of the 29 ECG patterns, 18 showed a significant association with the dependent variables on univariate analysis. Multivariate analysis revealed that atrial fibrillation, HR >100 bpm, low QRS voltage, QTc >500msec, diffuse nonspecific T-wave changes, and 'any AMI' ECG patterns correlate with disease severity;need for advanced ventilatory support and in-hospital mortality. S1Q3 and S1Q3T3 increased the odds of critical disease and need for high oxygen requirement by 2.5-3 fold. Fractionated QRS increased odds of advanced ventilatory support. Conclusion(s): The ECG can be useful for predicting the severity and outcome of more than moderate COVID-19. Their use can facilitate rapid triage, predict disease trajectory, and prompt a decision to intensify therapy early in the disease to make a positive impact on clinical outcomes.

Cardiovascular profile and electrocardiographic findings of hospitalized adult patients during the surge of delta and omicron variants of COVID-19 in a COVID-19 tertiary referral center

Background: COVID-19 has been reported to cause cardiac injury. It can be detected by an electrocardiogram (ECG), which may show markers that may predict clinical outcome. Robust data on the ECG abnormalities among COVID-19 patients affected by the alpha, beta, and gamma variants have been reported, but there is paucity of data among patients affected by the delta and omicron variants. Purpose(s): This study aims to describe the cardiovascular profile, ECG findings, and clinical course of adult patients with COVID-19, and to determine the association between certain ECG findings and clinical outcomes among these patients. Method(s): We evaluated 547 COVID-19 patients admitted from June 2021 to June 2022. Clinical profiles were extracted from electronic records. Admission ECGs were independently read and adjudicated by three cardiologists. Logistic regression analysis was done to determine the association between ECG abnormalities and adverse outcomes, including in-hospital mortality, ICU admission, need for mechanical ventilation, acute respiratory distress syndrome (ARDS), shock, acute kidney injury (AKI), myocardial infarction (MI), myocarditis, venous thromboembolism (VTE), and stroke. Result(s): A Total of 547 COVID-19 patients (mean age 54;men 51.2%) were included. The most common comorbidities were hypertension, diabetes, and dyslipidemia. Majority of patients had severe COVID-19 infection (36%). On admission, 6.4% needed intubation and 14.6% died. The most common ECG abnormalities were non-specific ST-T wave changes (41.1%) and sinus tachycardia (25.6%). Other findings were ST segment depression (3.3%), T wave inversion (1.6%), and ST segment elevation (1.3%). On logistic regression analysis, intraventricular conduction delay (IVCD), T wave inversion, and poor R wave progression were significantly associated with mortality;sinus tachycardia, atrioventricular (AV) block, ST segment elevation, and T wave inversion were significantly associated with the development of VTE;left axis deviation, ST segment elevation, and T wave inversion were significantly associated with the development of ARDS;sinus tachycardia, ST segment depression, and T wave inversion were significantly associated with the development of shock;and sinus tachycardia, ST segment elevation, and early repolarization changes were significantly associated with ICU admission. No associations were established for AKI, MI, myocarditis, and need for mechanical ventilation due to the low prevalence of these outcomes. Conclusion(s): A baseline ECG in patients with COVID-19 may help predict patients who may warrant hospitalization or even intensive care monitoring. In our cohort, certain ECG abnormalities, especially sinus tachycardia, left axis deviation, ST segment elevation, ST segment depression, T wave inversion, AV block, IVCD, poor R wave progression, and early repolarization changes, were associated with adverse clinical outcomes, including in-hospital mortality.

First-Degree Atrioventricular Block with Tachycardia from Paliperidone and Mirtazapine Overdose.

BACKGROUND: Paliperidone and mirtazapine are psychotropic agents associated with proarrhythmic effects. CASE PRESENTATION: A 21-year-old woman was admitted to the intensive care unit on two separate occasions for attempting suicide by overdosing on paliperidone and mirtazapine. During both admissions, the patient had atypical chest pain and a first-degree atrioventricular block (AVB) with paradoxical sinus tachycardia, which resolved with the discontinuation of paliperidone and mirtazapine and aggressive intravenous fluids. CONCLUSION: Drug-induced first-degree AVB from paliperidone and mirtazapine should be on the differential diagnosis in patients on paliperidone and/or mirtazapine who present with chest pain, tachycardia or new-onset first-degree AVB. LEARNING POINTS: Paliperidone and mirtazapine are associated with first-degree heart block, which may be a harbinger of torsades de pointes and ventricular fibrillation.Paliperidone and mirtazapine may potentiate each other's proarrhythmic effects since the metabolism of both involve the cytochrome P450 2D6 enzyme.A history of psychiatric illness makes it difficult to rule out atypical chest pain without ECG or troponins and often leads to increased resource utilization, even during times of heavy use like the COVID-19 pandemic.

Primary Cardiac Lymphoma with an Aggressive Hostile Take-Over

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

Fulminant myocarditis with complete atrioventricular block after mRNA COVID-19 vaccination: A case report.

A 71-year-old man was transferred urgently to our hospital after collapsing near his home post the first shot of the BNT162b2 coronavirus disease 2019 vaccine (Pfizer-BioNTech, Comirnaty®). Immediately after arrival at our hospital, cardiac arrest due to complete atrioventricular block with no ventricular escaped beats was observed on electrocardiogram. Echocardiography showed preserved left ventricular ejection fraction, however, diffuse severe hypokinesia was revealed after 3 weeks, and he died 3 months after admission because of worsening heart failure. An autopsy examination revealed eosinophilic myocarditis or hypersensitivity myocarditis with extensive fibrosis and widespread myocardial dropout throughout the heart. Learning objective: 1. Severe myocarditis occurs extremely rarely after mRNA coronavirus disease 2019 (COVID-19) vaccination. 2. Myocarditis after mRNA COVID-19 vaccination might cause complete atrioventricular block, followed by a course of decreased left ventricular ejection fraction. 3. Histologically, severe myocarditis after mRNA COVID-19 vaccination seems to present as fulminant necrotizing eosinophilic myocarditis or hypersensitivity myocarditis.

Reporting complete heart block in a patient with polyarteritis nodosa after COVID-19 vaccination.

Complete heart block (CHB) is a serious health condition, and polyarteritis nodosa (PAN) is an important autoimmune disease. In the COVID-19 pandemy, several vaccines were developed for the COVID-19 disease that shown several side effects, and some of these complications are still unknown. This is the first report of CHB in a patient with history of PAN after COVID-19 vaccination. A 68-year-old man with a history of PAN referred to our hospital, complaining of presyncope episodes and dizziness after receiving a COVID-19 vaccine. Physical examination, laboratory tests, and transthoracic echocardiography were normal. In his electrocardiogram, a narrow QRS complex, AV dissociation, and junctional escape rhythm were seen. Coronary angiography showed a mild coronary artery disease. The patient, suffering from PAN for years, was hypothesized due to CHB a few days after COVID-19 vaccination. This case report suggests that COVID-19 vaccines may interrupt the conduction system of the heart and the fact that underlying PAN may predispose to CHB following COVID-19 vaccination. Further studies are needed to accurately assess a possible association between PAN, CHB, and COVID-19 vaccines.

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.

Arrhythmias in the COVID-19 patient.

Coronavirus disease 2019 (COVID-19) has encompassed the globe since it was first observed just under 2 years ago. Although the disease is predominantly a respiratory illness, there have been observed complications throughout the various organ systems. Namely, cardiovascular complications, and, more specifically, arrhythmic complications have been described throughout the pandemic in patients with COVID-19. Management of atrial arrhythmias, ventricular arrhythmias, and bradyarrhythmias in patients with COVID-19 infection has been largely guided by our prior experience in the management of these arrhythmias in similar patient populations without infection. However, this review aims to highlight the specific considerations as they pertain to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) and the various arrhythmic manifestations observed with this disease.

Retrieval of an infectious leadless pacemaker with vegetation.

This case discusses the retrieval of a pacemaker with vegetation from a 78-year-old man. It suggests that grasping side of Micra body and pulling Micra into Agilis sheath is a possible technique for retrieval.