Cardiac Arrhythmias among Myocarditis Patients Positive with Covid-19 and Associated Mortality Risk, an Analysis from the 2020 National Inpatient Sample

Background: Viruses are the most common cause of myocarditis. With the ongoing COVID-19 pandemic, several cases of myocarditis have been reported in COVID-19 positive patients. Such patients may also experience a variety of arrhythmias that can provoke death. Objective(s): To evaluate the presence of various cardiac arrhythmias among COVID-19 positive myocarditis patients and understand their impact on mortality. Method(s): COVID-19 positive patients, admitted between April 1st 2020 to December 31st 2020, were recruited from the 2020 National Inpatient Sample. The presence of myocarditis and various cardiac arrhythmias were also identified via their respective ICD-10 codes. Logistic regression models were used to identify the odds of mortality in the presence of myocarditis. We further proceeded to estimate the odds of mortality among myocarditis patients who had various arrhythmias. Result(s): Our study found 6135 (0.4%) patients with myocarditis among 1628110 cases of COVID-19 recorded in the United States between April to December 2020. Age ranged between 0 - 90 years with a mean of 58 years. Multiple cardiac arrhythmias were also observed among myocarditis patients as 310 (5.1%) recorded supraventricular tachycardia, 520 (8.5%) had ventricular tachycardia, 120 (2.0%) had ventricular fibrillation, 520 (8.5%) had paroxysmal atrial fibrillation, 165 (2.7%) had atrial flutter, and 20 (0.3%) had long QT syndrome. The presence of myocarditis was linked with higher odds of mortality among all COVID-19 patients (aOR 2.551, 95% CI 2.405-2.706, p<0.01). Various cardiac arrhythmias were also potential predictors of mortality among myocarditis cases in COVID-19 patients, such as supraventricular tachycardia (aOR 1.346, 95% CI 1.041-1.74, p=0.023), ventricular tachycardia (aOR 1.896, 95% CI 1.557-2.308, p<0.01), ventricular fibrillation (aOR 4.161, 95% CI 2.74-6.319, p<0.01), and atrial flutter (aOR 1.485, 95% CI 1.047-2.106, p=0.026). Conclusion(s): Myocarditis was associated with higher mortality among COVID-19 admissions. Arrhythmias such as supraventricular tachycardia, ventricular tachycardia, ventricular fibrillation, and atrial flutter were predictive of higher mortality in these patients. Continued caution is advised among health-care providers encountering these arrhythmias in myocarditis patients who are COVID-19 positive. [Formula presented] French language not detected for EMBFRA articles source xmlCopyright © 2023

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.

The association of angiotensin-converting enzyme inhibitors and angiotensin 2 receptor blockers with renal protection in patients with SARS-CoV-2

Background: Kidney dysfunction is a prevalent disease that leads to many complications over time, such as hypertension, heart disease, and death. ACEI/ARBs are known to be renoprotective. However, few studies describe the association between ACEI/ARB use and kidney dysfunction in patients with SARS-CoV-2 infection. Purpose(s): To explore the association between patients with SARS-CoV- 2 and kidney dysfunction in patients taking an ACEI/ARB. We hypothesize a negative association between patients with SARS-CoV-2 taking an ACEI/ARB and kidney dysfunction. Method(s): A retrospective query between March 2020 and April 2021 was performed in patients 18 years and older who tested positive for SARSCoV- 2 using a polymerase chain reaction test. Patients were divided into two groups: Kidney dysfunction and no kidney dysfunction. Kidney dysfunction was defined as any diagnosis of chronic kidney disease or acute kidney injury. Primary outcomes were all-cause mortality and hospitalization rate. Secondary outcomes included myocardial infarction (MI), hypotension, intubation, vasopressor use, ventricular tachycardia, and ventricular fibrillation. We used multivariate logistic regression to adjust for baseline characteristics. Result(s): We identified 996 patients with kidney dysfunction and 22,106 without kidney dysfunction who tested positive for SARS-CoV-2. The incidence was 258 (25.9%) for ACEI/ARB use in patients with kidney dysfunction. Adjusted odds ratio (OR) for patients with kidney dysfunction was 5.705 (95% Confidence Interval [CI]: 4.554-7.146;p<0.001) for hospitalization, 0.895 (95% CI: 0.707-1.135;p<0.361) for patients taking ACEI/ARB, and 0.529 (95% CI: 0.333-0.838;<0.007) for mortality in patients with kidney dysfunction who took ACEI/ARB. All secondary outcomes had significantly greater adjusted OR (p<0.001), except for MI (p<0.339), ventricular tachycardia (p<0.697), and ventricular fibrillation (p<0.060). Conclusion(s): To date, the benefits of ACEI/ARB in SARS-CoV-2 patients have been controversial. While ACEI/ARB is known to have renoprotective properties, we did not find a significant association between ACEI/ARB and kidney dysfunction in patients with SARS-CoV-2. However, we found the use of ACEI/ARB in patients with kidney dysfunction to be associated with lower mortality. Therefore, clinicians should continue using this medication for its mortality benefits in patients with kidney dysfunction and its cardioprotective effects.

Phospholamban Mutation Leading to Recurrent Short-Coupled Polymorphic Ventricular Tachycardia and Fibrillation in Patient without Apparent Structural Heart Disease

Background Phospholamban (PLN), an inhibitor of sarcoplasmic reticulum (SR) Ca2+-ATPase, is a regulator of Ca2+ release during excitation-contraction coupling. We present a case of recurrent polymorphic ventricular tachycardia (PMVT)/ventricular fibrillation (VF) due to a PLN mutation. Case 38 year-old male presents after resuscitation following VF arrest. An ICD was implanted. Seven years later, he presented with VF storm requiring ventricular assist device support and he underwent catheter ablation of PVC triggers of VF arising from the moderator band. Because he had an ECG that was concerning for early repolarization syndrome, he was placed on quinidine and metoprolol. After an episode of VT in 2020 in the setting of COVID infection, whole genome sequencing was obtained and identified a pathogenic PLN mutation. PLN L39Ter has been associated with dilated and hypertrophic cardiomyopathy as well as sudden death. The patient has a history of normal left ventricular function and wall thickness by echocardiography. Decision-making Given the involvement of PLN on SR handling of Ca2+, flecainide may be a more effective therapy for the treatment of PMVT/VF in this patient. Conclusion PLN mutations have been associated with cardiomyopathies. This case illustrates a patient with the pathogenic PLN L39X variant with short-coupled PMVT with no imaging evidence of structural heart disease. Whether a more targeted therapy such as flecainide may be more effective in this patient remains to be determined. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

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

TRAINING THE LEADER: EFFECTIVENESS OF A SIMULATION AND CLINICAL SKILLS-BASED CURRICULUM ON RESIDENT COMFORT LEVEL AS CODE LEADERS

SESSION TITLE: Trainees: Mental Well-Being and Performance SESSION TYPE: Original Investigations PRESENTED ON: 10/16/22 10:30 am - 11:30 am PURPOSE: With the COVID-19 pandemic and hospital surges, our institution’s house staff was responsible for a significantly increased volume of critically ill patients while balancing residency training. In August 2020, a needs assessment survey was distributed among categorical Internal Medicine (IM) and Internal Medicine/Pediatrics (Med-Peds) residents. The results indicated low comfort levels in the evaluation of decompensating patients and in leading rapid response teams (RRTs). A grassroots initiative was started by two residents and a resuscitation nursing coordinator to address this need. Here, we describe the design and implementation of a resident-led simulation and clinical skills-based curriculum aimed at improving residents’ comfort in leading RRTs. METHODS: From August to September 2021, 56 senior level IM and Med-Peds residents attended a three-hour resuscitation workshop. A mixed educational format with high fidelity simulations, hands-on skills and small group debriefing discussions was implemented. Five scenarios were developed from retrospective hospital-wide RRT data;ventricular tachycardia (VT), supraventricular tachycardia (SVT), ventricular fibrillation, symptomatic bradycardia, and respiratory distress. Skills training included defibrillator use, transcutaneous pacing, adenosine administration, intraosseous line placement and low- and high-flow oxygen delivery devices. Participants were asked to complete a pre- and post-workshop questionnaire. The survey consisted of 7 questions about their comfort level on a 5-point Likert scale. A two-sample t-test was used to assess for difference in mean scores. RESULTS: Residents’ comfort level scores improved significantly in the following: from 3.49 to 4.36 (P< 0.0001) in the initial evaluation of an RRT patient, from 3.14 to 3.84 (P= 0.0026) in regard to thinking quickly during an emergency, and from 2.88 to 4.00 (P< 0.0001) in leading a RRT. There was also a global increase in comfort level scores with the scenarios: “VT” (P=0.0003), “SVT” (P< 0.0001), “symptomatic bradycardia” (P< 0.0001), and “respiratory distress” (P= 0.0324). CONCLUSIONS: Residents’ comfort levels as code leaders encountering various RRT scenarios significantly improved after our three-hour high-fidelity simulation and clinical skills workshop. CLINICAL IMPLICATIONS: Despite the challenges of COVID-19 group gathering restrictions and hospital surges, this training course became a well-received educational project to improve the effectiveness of resident-led RRTs. In response to its success, a pilot two-year curriculum involving more diverse RRT scenarios is currently being launched. The curriculum includes three workshop sessions per year for a multidisciplinary team of residents, pharmacy residents, and nurses aimed at improving code leader effectiveness and teamwork dynamics. DISCLOSURES: No relevant relationships by Tanja Barac No relevant relationships by Christie Brillante No relevant relationships by Lily Cheng No relevant relationships by Paul Cooper no disclosure on file for Cristina Diaz Pabon;No relevant relationships by Shaveta Khosla

COVID-19: A CONFOUNDING MIMICKER OF HEMOPHAGOCYTIC LYMPHOHISTIOCYTOSIS

SESSION TITLE: Challenging Cases of Hemophagocytic Lymphohistiocytosis SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: Hemophagocytic lymphohistiocytosis (HLH) is a rare syndrome involving pathologic immune activation that is often fatal. The link between the cytokine storm related to COVID-19 and development of HLH has been reported since the onset of the pandemic, but little is known about clinical manifestations of HLH, thereby delaying treatment. CASE PRESENTATION: A 50 year-old male presented with a several day history of progressive weakness in the setting of missed dialysis session. Medical history was significant for ESRD on dialysis and diastolic heart failure (EF 35%). Initial vitals were unremarkable. Physical exam was notable for peripheral edema bilaterally. Laboratory studies were consistent with hyperkalemia, elevated ferritin (28,383) and elevated liver function tests. COVID-19 PCR was positive upon admission. Chest x-ray, CTA chest and a right upper quadrant ultrasound were unremarkable. He was admitted to the medical ICU for emergent dialysis. Soon after arrival to the ICU, he became lethargic and confused with increasing oxygen requirements and a subsequent a code blue was called. Cardiopulmonary resuscitation was immediately initiated, with a first rhythm consistent with ventricular fibrillation. He was shocked and placed on an amiodarone infusion with return of spontaneous circulation. TTE revealed a severely reduced EF <10%. Despite initiation of advanced COVID-19 therapies with Solu-Medrol and tocilizumab he remained ventilator dependent. Due to hemodynamic instability and persistent metabolic acidosis, he was transitioned to continuous renal replacement. Further blood work showed worsening inflammatory markers (ferritin 33,500, LDH 6981). Because of the significantly elevated ferritin, there were concerns for possible HLH. Triglycerides and IL-2 receptor were 395 mg/dL and 9300 pg/mL respectively. Total NK cells were decreased to 1.2%. He remained persistently unstable despite aggressive measures. He suffered a second cardiopulmonary arrest, which was unable to achieve return of spontaneous circulation and he ultimately passed away. DISCUSSION: HLH is characterized by uncontrolled activation and proliferation of benign macrophages in reticuloendothelial organs. This results in histiocytic hemophagocytosis, worsening peripheral blood cytopenia(s), cytokine storm, and cytokine mediated biochemical alteration ultimately culminating in multiorgan dysfunction and disseminated intravascular coagulation. Although a distinctive constellation of features has been described for HLH, diagnosis remains challenging as patients have diverse presentations associated with a variety of triggers. CONCLUSIONS: As HLH is a medical emergency with poor prognosis, prompt recognition and early treatment is crucial for improving clinical outcomes. We hope this case will create increased awareness and timely diagnosis of cytokine storm syndromes in patients with severe COVID-19 infection. Reference #1: Meazza Prina M, Martini F, Bracchi F, Di Mauro D, Fargnoli A, Motta M, Giussani C, Gobbin G, Taverna M, D'Alessio A. Hemophagocytic syndrome secondary to SARS-Cov-2 infection: a case report. BMC Infect Dis. 2021 Aug 13;21(1):811. doi: 10.1186/s12879-021-06532-7. PMID: 34388982;PMCID: PMC8361241. Reference #2: Schnaubelt, Sebastian MDa,*;Tihanyi, Daniel MDb;Strassl, Robert MDc;Schmidt, Ralf MDc;Anders, Sonja MDb;Laggner, Anton N. MDa;Agis, Hermine MDd;Domanovits, Hans MDa Hemophagocytic lymphohistiocytosis in COVID-19, Medicine: March 26, 2021 - Volume 100 - Issue 12 - p e25170 doi: 10.1097/MD.0000000000025170 DISCLOSURES: No relevant relationships by Garrett Fiscus No relevant relationships by Niala Moallem No relevant relationships by Resham Pawar

MULTISYSTEM INFLAMMATORY SYNDROME IN ADULTS (MIS-A) FOLLOWING SARS-COV-2 INFECTION PRESENTING AS TOXIC EPIDERMAL NECROLYSIS

SESSION TITLE: COVID-Related Critical Care Cases SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: Multisystem Inflammatory Syndrome in Adult (MIS-A) is a rare hyperinflammatory response occurring 2 to 6 weeks after COVID-19 resembling Kawasaki disease. CASE PRESENTATION: A 23-year-old male presented to the emergency room with fevers, cough, shortness of breath, fatigue and painful rashes all over his body. 3 weeks prior, he was diagnosed with COVID-19 which was managed conservatively at home. He recovered within 3 days. He had received 2 doses of Moderna COVID-19 vaccine 6 months prior. He denied recent drug intake. Vitals were BP 116/78 mmHg, heart rate 164/min, temperature 97.3℉, SpO2 96% on room air. Physical exam revealed macular erythematous rash in his trunk and extremities. Leukocyte count was 4 k/uL, hemoglobin 15.5 g/dL, platelets 99 k/uL, sodium 126 mmol/L, bicarbonate 20 mmol/L, BUN 30 mg/dL, creatinine 2.2 mg/dL, lactate 5.1 mmol/L, ferritin >7500 ng/mL, total bilirubin 7.6 mg/dL, AST 298 U/L, ALT 291 U/L, ALP 106 U/L, procalcitonin 14.71 ng/mL, D-dimer 11.98 FEUug/mL. Troponin-I peaked at 1359 pg/mL. CT angiography of the chest showed clear lung fields without pulmonary embolism. Venous doppler was negative. Echocardiogram showed normal biventricular function and valves. An extensive infectious disease workup was negative. He was suspected to have MIS-A from recent COVID-19. He was started on methylprednisolone 1g/day, intravenous immunoglobulin (IVIG), anakinra and empiric antibiotics. Over the next 2 days, there was progression of rash with sloughing of skin in his trunk, back and extremities with bullae on his legs, and thigh sparing the face (figures). Skin biopsy revealed epidermal necrobiosis with apoptosis consistent with Toxic Epidermal Necrolysis (TEN). On day 3, he had a cardiac arrest from ventricular fibrillation but was successfully resuscitated. Subsequently, he was intubated, and required escalating vasopressor support for shock. On day 5, he also developed non-purulent conjunctivitis. On day 6, he was transferred to a higher center with a burns unit. However, despite aggressive supportive measures he succumbed to refractory shock the following day. DISCUSSION: Our patient fit the criteria for MIS-A outlined by CDC (1) with age ≥21 years, fevers, rash with non-purulent conjunctivitis for primary clinical criteria, hypotension and thrombocytopenia for secondary clinical criteria, several laboratory criteria, negative infectious work-up with a history of recent COVID-19. It is unclear if the COVID-19 vaccine increased his risk of MIS-A. There have been case reports of MIS-A presenting as TEN following COVID-19 and COVID-19 vaccines in the absence of typical triggering drugs. (2,3) MIS-A is treated with high dose steroids, IVIG, tocilizumab and supportive measures. Anakinra was used for our patient because of liver dysfunction. CONCLUSIONS: MIS-A following COVID-19 can also present as life-threatening skin reactions like TEN in the absence of triggering drugs. Reference #1: Retrieved from https://www.cdc.gov/mis/index.html Reference #2: Narang I, Panthagani AP, Lewis M, Chohan B, Ferguson A, Nambi R. COVID-19-induced toxic epidermal necrolysis. Clin Exp Dermatol. 2021;46(5):927-929. Reference #3: Kherlopian A, Zhao C, Ge L, Forward E, Fischer G. A case of toxic epidermal necrolysis after ChAdOx1 nCov-19 (AZD1222) vaccination. Australas J Dermatol. 2022;63(1):e93-e95. DISCLOSURES: No relevant relationships by Fady Jamous No relevant relationships by Swaminathan Perinkulam Sathyanarayanan

WHEN ST-ELEVATION MYOCARDIAL INFARCTION (STEMI) IS JUST THE BEGINNING: DISSEMINATED INTRAVASCULAR COAGULATION (DIC) FROM COVID-19 INFECTION PRESENTING AS ACUTE MYOCARDIAL INFARCTION

SESSION TITLE: Cardiovascular Complications in Patients with COVID-19 SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/19/2022 12:45 pm - 1:45 pm INTRODUCTION: COVID-19 is associated with a hypercoagulable state and has been linked with Disseminated Intravascular Coagulation (DIC) [1]. DIC causes systemic thrombosis in micro- and macro- vasculature and in rare instances can involve coronary arteries [2]. In this case report, we present a patient who presented as an ST-segment elevation myocardial infarction (STEMI) and DIC in the setting of severe COVID-19 disease. CASE PRESENTATION: A 46-year-old lady with a history of hypertension presented with acute onset of typical chest pain. She tested positive for COVID-19 infection. Emergency room EKG showed anterior STEMI, and the patient underwent cardiac catheterization via a femoral approach which revealed a 99% stenosis in the proximal LAD, with filling defects consistent with a thrombus. Thrombectomy was performed and three drug-eluting stents were placed in the left anterior descending artery. Following stent placement, the patient went into ventricular fibrillation cardiac arrest followed by PEA. ROSC was attained after 3 rounds of CPR. Labs showed an acute drop in hemoglobin from 14 gm/dL to 5 gm/dL with CT evidence of extensive retroperitoneal bleed, extraperitoneal bleed, and large abdominal aorta thrombus proximal to the bifurcation. Labs were significant for prolonged INR (2.1), PT (23.4 seconds), PTT (106.7 seconds), elevated D-dimer (>4.0), decreased platelets (101K/μl), and increased fibrin split products (80uG/mL) consistent with DIC. The acute aortoiliac occlusive thrombus resulted in acute limb ischemia, rhabdomyolysis causing renal failure, and compartment syndrome requiring bedside fasciotomy. She was treated with triple therapy and demonstrated gradual clinical improvement. DISCUSSION: DIC was a possible precipitant of STEMI in this patient with evidence of thrombotic occlusion of LAD. DIC is a life-threatening coagulopathy characterized by mixed hypo- and hypercoagulation. This often leads to a systemic distribution of clots, evidenced by thrombi present in the coronary and aortoiliac arteries. Historically, bacterial sepsis was more strongly linked with DIC than viral causes;however, there has been an increasing amount of evidence linking COVID-19 with DIC, likely due to the severity of the illness. In this patient with recent stent placement, large aortic thrombus, and extensive retroperitoneal bleed, management was complicated by need for dual antiplatelet therapy for drug-eluting stents as well as anticoagulation for acute limb ischemia. Another diagnosis to keep in the differential includes heparin-induced thrombocytopenia, characterized by similar findings to DIC, but is associated with antibodies against platelet factor 4, which was not found in our patient. CONCLUSIONS: In this case, a young female patient without traditional cardiac risk factors was found to have an anterior STEMI, likely precipitated by DIC as a complication of COVID-19 infection. Reference #1: Asakura, Hidesaku, and Haruhiko Ogawa. "COVID-19-associated coagulopathy and disseminated intravascular coagulation.” International journal of hematology vol. 113,1 (2021): 45-57. doi:10.1007/s12185-020-03029-y Reference #2: M. Sugiura, K. Hiraoka, and S. Ohkawa, "A clinicopathological study on cardiac lesions in 64 cases of disseminated intravascular coagulation,” Japanese Heart Journal, vol. 18, no. 1, pp. 57–69, 1977. DISCLOSURES: No relevant relationships by radhika deshpande No relevant relationships by Shruti Hegde No relevant relationships by Robert Kropp No relevant relationships by Prashanth Singanallur

Leptospirosis: A Consideration When Acute Liver Failure Accompanies Acute Kidney Injury (AKI)

A 48 y.o. male maintenance worker in a rat-infested building with history of tobacco and marijuana smoking, atrial fibrillation on no medications was admitted in July 2021 for fever, headache and body aches for 5 days and new onset of hemoptysis. Initial labs notable for BUN 36 mg/dl, Cr 1.4 mg/dl urine protein 100 mg/dl RBCs 5-10/hpf, platelets 46,000. total bilirubin 3.8 mg/dl direct bilirubin 3.0 SARS-CoV-PCR negative and CXR revealed patchy bilateral infiltrates. He was intubated on day 2 and had ventricular fibrillation and cardiac arrest on day 3 with rapid return of purposeful movement. He had worsening anemia and thrombocytopenia, positive ANA and dsDNA, leading to use of steroids and plasmapheresis on Day 6 when peak bun/cr was 91/3.1 with urine protein/cr ratio 0.7, urine microscopy 2 rbc/hpf, urine Na 20 meq/l, urine osm 775 mosm/kg and cpk 400 U/l. These tests were negative or normal: Anti-GBM, ANCA, repeat ANA, repeat dsDNA, C3, C4, HIV, RF, hepatitis C RNA, cryoglobulins, ASO titer, ADAMTS13, Pneumocystis PCR, Sputum AFB, blood, AFB and fungal cultures, viral and fungal testing, hanta virus antibodies. Leptospira antibodies IgM by Dot Blot were positive and Leptospirosis diagnosis confirmed by NYC Department of Health (DOH) after obtaining confirmatory microscopic agglutination testing from the CDC. Urine and blood Leptospira DNA PCR not detected. He remained intubated with FiO2 requirement at 100% prior to his death on hospital day 16. Initially pulmonary renal syndrome considered but he was later found to have pre-renal azotemia. The elevated bilirubin led to testing for leptospirosis, his final diagnosis. In September 2021 the NYC DOH reported 14 cases of leptospirosis (increased from 5 cases in 2020), 13 of which had acute renal and hepatic failure, with 2 having severe lung involvement (1). This case is the only one in this group who died. The leptospirosis case fatality rate for severe diffuse alveolar hemorrhage exceeds 50%. Early appropriate antibiotic treatment prior to lab confirmation has been recommended by the CDC and may decrease severity of disease.

Defer Thy Diuresis

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

Prevalence and impact of dysrhythmias in COVID-19 intensive care patients

Background: The COVID-19 pandemic has had a dramatic impact on clinical practice, amounting to more emergency department and intensive care unit (ICU) admissions. Due to their frequent multiple comorbidities, management in the ICU is challenging. Early studies suggest that cardiac injury is frequent in hospitalized patients with COVID-19, and it is plausible that these patients have a higher risk of cardiac dysrhythmias. Purpose: To determine the prevalence of dysrhythmias in ICU patients with COVID-19 pneumonia, identify major predictors and determine the impact on in-hospital mortality. Methods: A retrospective study of 98 consecutive patients with COVID-19 Pneumonia admitted to the ICU of a tertiary hospital in 2020. The main outcome was dysrhythmias (including significant bradycardia, high/slow ventricular rate or new-onset atrial fibrillation (AF) or atrial flutter, other supraventricular tachycardias, ventricular tachycardia and ventricular fibrillation). Significant bradycardia was defined as heart rate lower than 40 or need of treatment. Sociodemographic variables and clinical data were retrieved for each patient, severity scores at admission (Apache II, SOFA and SAPS II), number of days on mechanical ventilation or high-flow oxygen and placement on Venovenous Extracorporeal Membrane Oxygenation (ECMO) or prone position were recorded. Statistical comparison was made between groups, including logistic regression adjusting for confounding variables. Results: The most frequent arrhythmia was significant sinus bradycardia (28, 28.5%) followed by high ventricular rate AF (14, 14.2%). Patients who had dysrhythmias were older (66.24 ± 10.13 vs 60.85 ± 12.69 years, p 0.024), more severe (SAPS II score 42.55 ± 11.08 vs 35.98 ± 11.26, p 0.006), had more atrial fibrillation (AF) (p 0.022), had higher maximum C-reactive protein (mCRP) (6.56 ± 2.68 vs 6.24 vs 2.86, p 0.009), were mechanically ventilated for a longer time (15.64 ± 13.18 vs 8.92 ± 8.85 days, p 0.004), had longer intubation time (14.52 ± 9.39 vs 8.70 ± 8.21 days, p 0.002) and had higher usage of dexamethasone (p 0.042) and prone position (p 0.016). When adjusted for confounding variables, prone was the most significant predictor (OR 2.800;95% CI 1.203-6.516) followed by use of dexamethasone (OR 2.484;95% CI 1.020-6.050). Days intubated, days on mechanical ventilation, age, mCRP and SAPS II on admission were also predictors of dysrhythmia. Regarding mortality, patients with arrhythmic events had a tendency for greater in-hospital death (OR 2.440;95% CI 0.950-6.310;p 0.065). Conclusions: COVID-19 ICU patients are a subset of patients at risk of cardiac arrhythmias. Use of prone position was the main contributor to these events, but clinical history, severity and treatment may also play an important role. Efforts must be made to optimize ventilatory support and treatment in order to reduce the risk of dysrhythmias. (Figure Presented).

Tachydysrhythmias in patients admitted with COVID-19 pneumonia: prevalence and impact on in-hospital mortality

Background: The COVID-19 pandemic has shifted tremendously the paradigm of hospital care and treatment of cardiovascular (CV) patients. According to most recent evidence, due to its multisystemic impact, COVID-19 may lead to an increased risk of cardiac arrhythmias with subsequently increased morbimortality. Purpose: Determine the prevalence of tachyarrhythmias in patients admitted with COVID-19, possible predictors and impact on in-hospital mortality. Methods: A retrospective study of 3475 consecutive patients with COVID-19 pneumonia admitted to our hospital between February 2020 and November 2021 were included. The main outcome was tachyarrhythmias (high ventricular rate (HVR) or new-onset atrial fibrillation (AF), HVR or new-onset atrial flutter (AFL), other supraventricular tachycardias (SVT), ventricular tachycardia (VT) and ventricular fibrillation (VF)). Secondary outcome was in-hospital mortality. Sociodemographic variables and clinical data were recorded. Statistical comparison was made between groups, including logistic regression to determine odds ratios (OR). Results: A total of 215 patients presented HVR AF (6.31%), 79 of which with new-onset AF (36.74%). 8 patients had HVR AFL (0.23%), 5 VT (0.15%), 4 VF (0.12%) and only 3 patients had a SVT identified (0.09%). Patients with tachyarrhythmias were significantly older (77. 74 ± 11.25 68.94 ± 17.51 years, p <0.001) and had more hypertension (p 0.034), heart failure (HF) (p <0.001), severe valvular heart disease (VHD) (p 0.007), coronary artery disease (CAD) (p 0.031), chronic kidney disease (CKD) (p 0.048) and paroxysmal AF (if previously diagnosed (p 0.001). There were no significant differences regarding gender, dyslipidemia, diabetes, cerebrovascular disease and obstructive sleep apnoea (OSA). Patients with HF had the highest risk of tachyarrhythmia (OR 3.539;95% CI 2.666-4.698;p <0.001), followed by severe VHD (OR 1.990;95% CI 1.192-3.365;p 0.009) and CAD (OR 1.575;95% CI 1.040-2.386;p 0.032). Older patients or patients with hypertension or CKD were also at an increased risk. Also of note, patients previously diagnosed with paroxysmal AF were more likely to have episodes of HVR AF than the ones with persistent or permanent AF (OR 1.819;95% CI 1.272-2.602;p 0.001) Regarding the secondary outcome, patients with tachyarrhythmias during hospital stay had an odd almost 3 times higher of death (OR 2.820;95% CI 2.151-3.695;p <0.001). Conclusions: Tachyarrhythmias is a common complication in COVID-19 patients during hospital stay that is significantly linked to higher in-hospital mortality. Patients presenting with high CV disease burden are at particularly significant risk and should be carefully managed. Odds-ratio of tachyarrhythmias (Figure Presented).

THE TREATMENT WITH BETA-BLOCKERS AFTER MYOCARDIAL INFARCTION WITHOUT REDUCED EJECTION FRACTION (REBOOT) TRIAL. CURRENT STATUS

Background: There is a lack of evidence regarding the benefits of maintenance β- blocker (BB) treatment in post-acute AMI patients (pts) without reduced LVEF in the era of invasive management. Design and Trial Status: REBOOT is an independent multinational pragmatic, controlled, randomized, open-label, with blinded endpoint adjudication clinical trial testing the benefits of BB maintenance therapy in post-AMI pts (either with or without ST segment elevation) discharged with LVEF >40%. Patients ≥18 years (yr) old undergoing invasive management during admission and without history of heart failure (HF) are eligible to participate. At discharge, pts are 1:1 randomized to either receive BB (agent and dose chosen by the treating physician) or no BB therapy. The primary endpoint is a composite of “all-cause death, nonfatal reAMI, or HF hospitalization” over a minimum follow-up period of 2 yr. Key secondary endpoints are: a) the incidence rate of each individual component of the composite endpoint;b) cardiovascular death;c) admission for sustained ventricular tachycardia/ventricular fibrillation;and d) admission for atrial fibrillation. Events will be adjudicated by a blinded committee. A sample size of 8468 pts (728 events) was estimated to provide a power of 85% to detect a relative risk reduction of 20% (incidence of primary endpoint in control 10%) and assuming 5% withdrawals. Statistical analyses will be conducted according to the intention-to-treat principle, although a pre-specified per-protocol analysis will also be performed. The Spanish National Center for Cardiovascular Research (CNIC) is the sponsor of the trial, which has no external funding. CNIC coordinates ≥75 Spanish centers, while Istituto di Ricerche Farmacologiche Mario Negri IRCCS coordinate 33 Cardiology Centers distributed in 10 Italian regions. The first pt was included in Spain in October 2018, in Italy in January 2019. The end of enrollment is anticipated in December 2022. At 09 December 2021, 5669 pts had been enrolled from which 1263 in Italy (Figure). Pts baseline characteristics are described in the Table. Hospital admission data for COVID-19 pre and post randomization were also recorded since June 2020. Conclusions: The REBOOT trial (NCT03596385) will fill the existing scientific gap on the efficacy of β-BB after AMI in pts with LVEF > 40% and no HF who are treated according to current standard-of-care. REBOOT trial results might have an impact on clinical practice guidelines. (Figure Presented).

Impact of SARS-CoV-2 on extra-hospital cardiac arrest

Introduction : The pandemic caused by the SARS-CoV-2 virus has affected nearly 240 million people around the world. This pandemic has had a great impact on individual and collective clinical practice. Objective : Impact of SARS-CoV-2 on out-of-hospital cardiac arrest (OCAH), through gender, context, initial rhythm, survival and neurological recovery. Design, settings, and participants : A retrospective analysis of a cohort of OCAH patients who were treated by the mobile emergency and intensive care unit (MICU) of the Erasme hospital - University clinics of Brussels was conducted. All interventions concerning an OCAH, from 01/01/2019 to 12/31/2019, reflecting a non-pandemic period and from 01/01/2020 to 12/31/2020, reflecting a period of SARSCoV-2 pandemic were analyzed. Main results : This study shows an increase in the male/ female ratio, as well as an increase in the number of OCAH. During the second wave, more than half of OCAHs had a suspected respiratory etiology. This period indicate an increase in ventricular fibrillation, as well as better autonomy and neurological sequelae, despite the statistical tests between a non-pandemic and a pandemic SARS-CoV-2 period were not significant. Conclusion : This retrospective cohort of patients who used MICU of HE-CUB during a non-pandemic and a pandemic period, highlights the impact of SARS-CoV-2 in absolute numbers on OCAH.

OUTCOMES IN PATIENTS WITH COVID-19 COMPLICATED BY HIGH GRADE ATRIOVENTRICULAR BLOCK

Background: There is growing evidence showing that arrhythmias are one of the major complications of COVID-19.However, there are currently only a few case reports of high-grade atrioventricular block (AVB). We sought to describe a large case series of AVB as a complication of COVID-19. Objective: The purpose of the current study is to describe a large case series of AVB as a complication of COVID-19. Methods: We included a series of twenty-five (25)consecutive patients with confirmed COVID-19, who developed advanced AVB in a prospective observational multi-center study. Patients underwent clinical, laboratory evaluation, Holter, telemetry, Echocardiogram, Chest X-Ray, chest CT scan and cardiac MRI Results: Of the 25 patients 13 were male with a mean age of 62+-13 years. 19 developed complete AVB, one a 3:1 AVB and five 2:1 AVB. None of the patients had a history of cardiac arrhythmia. AVB was not related to medication or intubation. Eighteen patients developed AVB during their hospitalization for COVID-19 and 7 after the first month as a late sequela. Five patients were asymptomatic, 6 presented syncope, seven dyspnea and seven dizziness. Eleven patients presented reverse AVB early by a high dose of corticosteroid in all of them, and combined with colchicine in 4 cases, with no recurrent episodes. 13 patients required a permanent pacemaker for persistent conduction defect (52%) and one died of ventricular fibrillation without pacemaker Conclusion: Advanced AVB could be a complication of COVID-19. The conduction disturbance was reversed by corticosteroids with or without colchicine in eleven of twenty five cases (44%)The resolution with corticosteroids of the advanced AVB in these patients could reflect the transient nature of the viral infection and the inflammatory response associated with it in some patients. 13 patients required a pacemaker(52%). Physicians should be aware of this complication.

Index of cardiac electrophysiological balance (iCEB) in patients with COVID-19

Aims: We aimed to examine whether there is abnormal value of index of cardiac electrophysiological balance (iCEB=QT/QRS) in patients with confirmed coronavirus disease 2019 (COVID-19), which can predict ventricular arrhythmias (VAs), including non-Torsades de Pointes-like ventricular tachycardia/ventricular fibrillation (non- TdPs-like VT/VF) in low iCEB and Torsades de Pointes (TdPs) in high iCEB. We also investigated low voltage ECG among COVID-19 group. Methods and Results: This is a cross-sectional, single center study with a total of 53 newly diagnosed COVID-19 patients (confirmed with polymerase chain reaction (PCR) test) and 63 age and sex-matched control subjects were included in the study. Electrocardiographic marker of iCEB were calculated manually from 12-lead ECG. Low voltage ECG defined as peak-to-peak QRS voltage less than 5mm in all limb leads and less than 10mm in all precordial leads. Patients with COVID-19 more often had low iCEB, defined as iCEB below 3.24 compared to control group (56.6% vs 11.1%), (OR=10.435;95%CI 4.015 - 27.123;p=0.000). There were no significant association between COVID-19 and high iCEB, defined as iCEB above 5.24 (OR=1.041;95%CI 0.485 - 2.235;p=0.917). There were no significant difference of the number of low voltage ECG between COVID-19 and control groups (15.1% vs 6.3%), (OR=2.622;95%CI 0.743 - 9.257, p=0.123). Conclusion: In this study showed that patients with COVID-19 are more likely to have low iCEB, suggesting that patients with COVID-19 may be proarrhytmic (towards non- TdPs-like VT/VF event), due to the alleged myocardial involvement in SARS-CoV-2 infection.

ACUTE MYOCARDIAL INFARCTION WITH VESSEL OCCLUSION IN A YOUNG ADULT WITH A MECHANICAL AORTIC VALVE

Background: The occurrence of myocardial infarction (MI) with coronary vessel occlusion in an otherwise young, healthy adult with a mechanical aortic valve is rare. Case: A 25-year-old male with a history of congenital AS status-post mechanical aortic valve replacement presented to the hospital with an acute MI due to thromboembolism due to subtherapeutic INR. The patient developed ventricular fibrillation en route to the emergency department. Return of spontaneous circulation was achieved after one round of CPR with synchronized cardioversion. On admission, labs were significant for high sensitivity troponin >27,000 x 3, BNP 23, INR 1.8. The patient was positive for COVID-19 but was asymptomatic. EKG showed ST elevations in leads I, AVL with reciprocal depressions in leads II, III and AVF. The patient underwent an emergent left heart catheterization which showed a normally functioning mechanical aortic valve and 100% occlusion of the mid LAD. After several rounds of balloon angioplasty, a thrombus was aspirated, mechanical thrombectomy was performed and a drug-eluding stent was deployed under IVUS guidance with restoration of TIMI 3 flow. A transthoracic echocardiogram following PCI showed an ejection fraction of 40% with anterior wall hypokinesis and mean aortic valve gradient of 10mmHg. The patient followed up in clinic two months later and was doing well. Decision-making: The effect of valvular heart disease on heart failure and cardiogenic shock is well studied. However, the occurrence of myocardial infarction due to thromboembolism in young patients with a subtherapeutic INR in the setting of mechanical aortic valve is not well described in literature. Conclusion: This case highlights both the importance of compliance with anticoagulation in patients with mechanical valves and a rare cause of myocardial infarction;i.e., non-compliance with anticoagulation in the setting of mechanical aortic valve. In addition, COVID-19 has been well established as a prothrombotic disease process, adding to the plot of this unusual case.

Global vasospasm treated with simultaneous use of anti-hypertensive and vasopressor

Case Report A Rare Presentation of Multivessel Vasospastic Angina in the Setting of Septic Shock Background Prinzmetal or vasospastic angina is an unusual but important consideration when evaluating a patient with chest pain. Unlikely acute coronary syndromes (ACS) which primarily occur as a result of coronary artery occlusion, prinzmetal angina occurs angina occurs mainly as a result of coronary artery vasospasm. We present the unusual case of a patient who suffered cardiac arrest and was found to have >90% occlusion in multiple coronary arteries on a left heart catheterization (LHC) performed within 60 minutes. Case presentation Patient is a 70-year-old female who was initially being treated in the hospital for COVID-19. She spent a few days in the ICU due to requiring high flow nasal cannula but was transferred to the floor after she was weaned down to 3L/min via regular nasal cannula. On day of arrest, patient had increasing oxygen requirements and was on ventimask immediately prior to the code blue. Patient received 2 rounds of CPR and her initial rhythm was found to be ventricular fibrillation. Pt was defibrillated and ROSC was immediately achieved. EKG showed ST elevations in inferior leads. Patient was, however, alert and oriented x3 on initial evaluation by critical care team. She was not intubated after the arrest. She was transferred to the intensive care unit, given 300 mg intravenous amiodarone and therapeutic dose lovenox. On LHC, her left anterior descending artery (mid/ distal portion), distal diagonal vessel, left circumflex artery (mid portion), distal portion of the obtuse marginal and right coronary artery were found to be severely spasmodic. Patient had recurrence of angina after the catheterization which was transiently relieved with nitro. Patient had sustained relief of angina after starting nitro drip. Patient was also started on amiodarone drip upon transfer back to the ICU. Discussion The obvious side-effect of our therapeutic treatment was hypotension that was initially responsive to intravenous fluids. Patient, however, became hypoxic a few hours later and needed to be diuresed to return to baseline oxygen requirement. Patient was then started on norepinephrine drip with goal to maintain mean arterial pressure above 65. After patient was loaded with amiodarone, nitro drip was discontinued. She was then transitioned to oral amiodarone. She was started on isosorbide dinitrate prior discontinuing nitro drip. Patient's blood pressure stabilized as her per oral intake improved and norepinephrine drip soon thereafter. Novel presentations require novel treatment and creative thinking lead to the decision to continue nitro drip to keep her stable, even if it meant the simultaneous use of an anti-hypertensive and a pressor. It is possible that COVID-19 served as a trigger for such a global vasospasm event. Patient was restarted on her home medication of long-acting nitrates which were held on admission due to hypotension.

Ventricular fibrillation storm in COVID 19 responding to steroid therapy: A case report

Cardiac arrhythmias are common in patients of COVID -19 and frequently complicate the clinical course of critically ill patients. Life threatening arrhythmia including ventricular fibrillation less common but are reported to be more common in patients with elevated cardiac troponins. The mechanisms of arrhythmia in COVID 19 are multifactorial and arise from either direct cardiac involvement, from consequences systemic affection or drug interactions. The successful management requires correct identification of the cause. We report a case of VF storm in a patient with COVID 19 who responded to steroid therapy. Controlling the fulminant inflammation may reduce the burden of arrhythmia in appropriate cases.