Covid-19 Vaccine Associated Acute Myocarditis

Case Presentation: A 19 year old male presented with sudden onset chest pain radiating to back. He was a smoker and denied using cocaine since his last hospitalization for cocaine-induced myocardial infarction 2 years ago. UDS was negative. EKG showed normal sinus rhythm with no ST-T wave changes. Initial troponin was 0.850. Potassium levels were low at 2.9 mmol/L but other labs were normal. Chest CT angiography ruled out aortic dissection. He was started on heparin drip. Stat Echocardiogram showed LVEF of 55-60% with no wall motion abnormalities. Repeat potassium levels normalized after replacement, however, his troponins were trending up from 3.9 and 11.5. He continued to complain of severe chest pain, so underwent cardiac catheterization which showed normal coronary arteries and LVEF 55-60%. Heparin drip was discontinued and NSAIDs and colchicine were started. Cardiac MRI (see Figure) was done that showed patchy mid-wall and epicardial delayed gadolinium enhancement involving the basal inferolateral wall, with mild hyperintense signal on the triple IR sequence, suggestive of myocarditis. On further probing, he reported receiving a second dose of Moderna COVID vaccine 3 days prior to presentation. Discussion(s): In December 2019, a novel RNA virus causing COVID-19 infection was reported, which quickly reached a pandemic level. COVID-19 vaccines were granted emergency use authorization by FDA. With millions of people receiving COVID-19 vaccinations worldwide, rare adverse effects are now being reported. The benefits of vaccination undoubtedly outweigh any minor side effects. However major adverse effects like this are potentially fatal. This case report warrants further investigation into the association of myocarditis with COVID-19 vaccinations and further recommendations regarding vaccination in younger adults.

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).

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.

Multivessel Epicardial Coronary Artery Thrombosis after Heart Transplantation

Introduction: Although cardiac allograft vasculopathy (CAV) remains one of the leading causes of graft failure after heart transplantation (HTx), simultaneous thrombosis of multiple epicardial coronary arteries (CA) is an uncommon finding. Case Report: A 43-year-old male patient with non-ischemic dilated cardiomyopathy underwent successful HTx in 2019. The first two years after HTx were uneventful, surveillance endomyocardial biopsies (EMB) did not reveal any rejection episodes, coronary CTA revealed only minimal non-calcified CA plaques. The patient was admitted to hospital due to fever and chest pain in 2021. Immunosuppressive therapy consisted of tacrolimus, mycophenolate-mofetil and methylprednisolone. ECG verified sinus rhythm. Laboratory test revealed elevated hsTroponin T, NT-proBNP and CRP levels. Cytomegalovirus, SARS-CoV-2-virus and hemoculture testing was negative. Several high-titre donor-specific HLA class I and II antibodies (DSAs;including complement-binding DQ7) could have been detected since 2020. Echocardiography confirmed mildly decreased left ventricular systolic function and apical hypokinesis. EMB verified mild cellular and antibody-mediated rejection (ABMR) according to ISHLT grading criteria. Cardiac MRI revealed inferobasal and apical myocardial infarction (MI);thus, an urgent coronary angiography was performed. This confirmed thrombotic occlusions in all three main epicardial CAs and in first diagonal CA. As revascularization was not feasible, antithrombotic therapy with acetylsalicylic acid, clopidogrel and enoxaparin was started for secondary prevention. Tests for immune system disorders, thrombophilia and cancer were negative. Patient suddenly died ten days after admission. Necropsy revealed intimal proliferation in all three main epicardial CAs, endothelitis, thrombosis, chronic pericoronary fat inflammation, fat necrosis, and subacute MI. CA vasculitis owing to persistent high-titre DSAs, chronic ABMR and acute cellular and antibody-mediated rejection led to multivessel CA thrombosis and acute multiple MI. ABMR after HTx may be underdiagnosed with traditional pathological methods. Pathologies affecting coronary vasculature of HTx patients with DSAs, unique manifestations of CAV lesions and occlusive thrombosis of non-stenotic, non-atherosclerotic lesions should be emphasized.Copyright © 2023

Cardiac dysrhythmias among coronavirus-19 recovered symptomatic patients

Background: The coronavirus (COVID-19) pandemic, which affected millions of people worldwide, is associated with a chronic fatigue sequela, also known as long-COVID. While various adverse effects of COVID-19 on the cardiovascular system were reported, the prolonged sequela of COVID-19 on heart rhythm remains unknown. Aim(s): To describe the prevalence of cardiac dysrhythmias among patients who presented with Long Covid following recovery from COVID-19 infection. Method(s): We conducted a prospective study among 87 patients who suffered from Long Covid syndrome following recovery from COVID-19 and were treated in the COVID-19 recovery clinic between December 2020 and June 2021. All patients were referred for transthoracic echocardiography (TTE) and 24-hour Holter examination. Result(s): The mean age was 52+13 years, and 52 (59.8%) patients were females. Seventy-nine (90.8%) of the patients had normal sinus rhythm without evidence of any arrhythmias. Atrial premature beats were recorded in 70 (80.5%) patients with a median of 6/day (interquartile range 3-20/day;maximum: 5180/day). Ventricular premature beats were recorded in 50 (57.5%) patients with a median of 4/day (interquartile range 2-19/day;maximum: 6847/day). Overall, seven patients (8%) had sustained atrial dysrhythmias: One had atrial fibrillation, one had atrial flutter, and five had atrial tachycardia. Sixty-six (75.9%) patients underwent TTE, which was mainly unremarkable as 65 patients had a normal left ventricular function, and three (4.5%) patients had evidence of pulmonary hypertension. Discussion(s): Cardiac arrhythmias are not uncommon among symptomatic COVID-19 recovered patients. Atrial arrhythmias were most common, with an up to 8% incidence rate. These findings may suggest that atrial dysrhythmias may be associated with long-term symptomatic sequela of COVID-19 infection.

Symptomatic Myocarditis After Pfizer Covid-19 Vaccination

Widely considered safe, effective, and essential for pathogenic immunity, vaccines have proven to be one of the most important discoveries to date in medicine. Adverse reactions to vaccines are typically trivial but there have been extremely rare reports of vaccine induced myocarditis, particularly with the Tdap vaccine. This is thought to be due to a hypersensitivity reaction. In efforts to combat the SARS-CoV-2, prompt response from Pfizer-BioNTech and Moderna lead to vaccine development with a novel method, synthesized from modified messenger RNA. Despite minimal side effects on initial trials, reports of vaccine induced myocarditis have resulted. A majority of these cases occurred following subsequent doses for those previously inoculated. A descriptive study published in JAMA in January 2022 reviewed the Vaccine Adverse Event Reporting System (VAERS) in collaboration with the CDC described only 1626 cases of myocarditis, of which the majority occurred within days of the second dose. This review was limited by reviewing a passive reporting syndrome with variable quality data and without follow up data post diagnosis of myocarditis. Here we present a case of myocarditis occurring less than 24 hours after the second dose of Pfizer-BioNTech vaccine with 3 month follow up. A 23 year old man received his second dose of the COVID-19 vaccine in the morning. Within a few hours he experienced chest pain, chills, weakness, and fatigue. These dissipated by 7pm. He is a member of the National Guard and during drills the next day experienced stabbing substernal chest pain for which he sought evaluation. The pain radiated into his left jaw, worse with deep inspiration and worse in the left lateral decubitus position. He is a 1 PPD smoker with no personal or family history or cardiac disease. A friction rub was heard on physical exam. His troponin I peaked at 2.6ng/mL. His EKG showed normal sinus rhythm, a TTE showed a normal EF with no pericardial effusion. He was given aspirin 81 mg and started on a heparin drip for possible NSTEMI. The next day his pain decreased and a cardiac MRI demonstrated no inflammation. His serum coxsackie and parvovirus titers were negative. He was instructed to continue the aspirin, limit exercise for 8 weeks, and stop smoking. Upon follow up 3 months later the patient denied any recurrent chest pain and was advised to continue the aspirin. But the original bout of myocarditis limited his participation in the National Guard. Our case illustrates that exposure to an immunological trigger, the COVID-19 vaccine, leading to myocarditis was extremely short compared to typical cases of viral induced or vaccine hypersensitivity reaction. A proposed mechanism is molecular mimicry between the spike protein and myocardial contraction proteins. It also demonstrates that the vaccine can cause morbidity in patients, especially younger males. It also exemplifies that this may be a short lived phenomenon, long term follow up is still needed. With the rate of vaccination increasing, there needs to be a low threshold to consider myocarditis in young adults who have new chest pain after receiving an mRNA based vaccine.Copyright © 2022

A CNN for COVID-19 Detection Using ECG signals

We developed an end-to-end automatic algorithm for the detection of signs of COVID-19 virus infection in ECGs. We analyzed 12-lead ECGs from patients infected by COVID-19 (C-group) and from a control group (NC-group). The C-group (896 cases) included patients (age range [19-96] years) hospitalized at Ospedale San Matteo in Pavia (Italy) during the first 2020 pandemic outbreak. Infection was confirmed by nasal swab testing. The NC-group (also 896 cases) was built by collecting ECG in sinus rhythm from 3 datasets: Georgia ECG (USA), PTB-XL (Germany) and CPSC 2018 (China). Control ECGs were matched by gender, age and heart rate. An additional control group, only used for testing, was extracted from the Ningbo (China) database. A 4-layers convolutional neural network (CNN), with increasing filter size plus a final fully connected (FC) layer, was designed to classify C vs NC-group. The CNN was trained and k-fold cross validated (k=7) on 1536 ECGs (1316 for testing-220 for validation). Every fold model was used to classify the remaining, separate common test set of 256 ECGs. The accuracy was 0.86 ± 0.01 on validation, 0.86 ± 0.01 on the test set. The FPR on the NC-group was 0.14 ± 0.03 on validation, 0.13 ± 0.02 on test and 0.10 ± 0.01 on the Ningbo test set (p > 0.05,ns) showing that no bias was induced by the selection of datasets. © 2022 Creative Commons.

COVID-19 and Spontaneous Coronary Artery Dissection: Association or Causality

Clinical Information Patient Initials or Identifier Number: JS Relevant Clinical History and Physical Exam: A 55-year old woman was brought to emergency department complaining of sudden onset squeezing chest pain radiating to her arm and jaw and associated with giddiness. She had flu like illness a day prior to her presentation associated with malaise, arthralgia and dry cough. She had history of hypertension. Physical examination revealed dual heart sounds and clear lung fields to auscultation. Relevant Test Results Prior to Catheterization: Electrocardiogram (ECG) showed normal sinus rhythm and the cardiac enzymes were elevated;high sensitivity troponin-I, 23000 ng/L (range0-10 ng/L). RNA PCR was positive for SARS-CoV-2 (COVID-19). D-Dimer was 303microgram/L (normal <500). Transthoracic echocardiogram showed severe hypokinesis of the mid inferolateral wall with left ventricular ejection fraction (LVEF) 52%. Chest X-ray showed no focal consolidation. [Formula presented] [Formula presented] Relevant Catheterization Findings: Invasive coronary angiogram showed tortuous coronary arteries with abrupt narrowing of mid- distal Ramus Intermiedius and discrete lesion of mid PDA. SCAD (spontaneous Coronary dissection) of Ramus Intermedius and mid PDA (posterior descending artery) was suspected, and patient was treated conservatively. Repeat coronary angiography, few months later showed complete resolution of SCAD with normal appearance of affected vessels. [Formula presented] [Formula presented] [Formula presented] Interventional Management Procedural Step: After obtaining an informed consent right Radial access was achieved with 6F Terumo sheath using over the wire technique. 1% lignocaine was used as local anaesthetic. 5F JL 3.5 (Judkin's) and JR 4 catheters were used to engage left main stem (LMS) and right coronary artery (RCA) and selective coronary angiography was performed. No percutaneous coronary intervention was performed. After the procedure hemoband (TR band) was applied to access site. Patient remained hemodyanamically stable throughout the procedure. [Formula presented] [Formula presented] [Formula presented] Conclusion(s): SCAD is a potential cause of type II myocardial infarction in patients with COVID-19, but more studies are needed to establish causality. Infection-related SCAD may occur at any time during index events and could be difficult to diagnose. Conservative management seems like a safe strategy.Copyright © 2023

Post Covid-19 with myocarditis: A case report

Introduction: Covid-19 infection, caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is a leading cause of morbidity and mortality worldwide. Myocarditis or pericarditis is a common clinical manifestation reported during the acute illness of Covid-19 infection. However, it is rarely reported during the recovery period or as part of post-Covid 19 conditions. We are reporting a case of a pregnant lady presented with post-covid 19 myocarditis with RVOT VT. Case presentation: A 44-year-old lady, Gravida 7 Para 6, presented to us at 32 weeks POA with the complaint of palpitation of 1 week, which was more frequent and persistent on the day of admission, associated with a presyncopal attack. Otherwise denied chest pain, fever or joint pain, or swelling. She had a history of Covid 19 infection 1 month prior to the onset of palpitation and had received 2 doses of SINOVAC vaccination. Upon presentation in the emergency department, she was tachycardic;however, her BP was normotensive and afebrile. Blood Investigations were unremarkable. ECG showed short run VT which self-reverted to sinus rhythm. Upon admission to CCU, she had multiple episodes of stable VT, which self-reverted to sinus rhythm. Echo showed EF 60% with no regional wall motion abnormality or valvular lesion. Cardiac MRI reported LV function of 46% with suspicion of fibrosis at the mid-septal wall. While in the ward, she had polyarthralgia, which improved with hydrocortisone. Blood investigation showed elevated inflammatory markers;otherwise, blood culture and ASOT were negative. Further investigations sent for connective tissue disease showed a positive result for ANA and ENA;however, it does not fulfill the SLICC criteria. Hence, we diagnosed her post covid 19 related myocarditis. She is currently generally asymptomatic with low-dose prednisolone and has been closely monitored for manifestation that may represent SLE. Discussion(s): The incidence of myocarditis in Covid-19 infection is 0.12%, which is 2-3 folder higher than non- covid 19 infection pneumonia;however, the prevalence in post covid infection is still unknown. It has been demonstrated that infectious causes are a significant initiating event in the pathophysiology of autoimmune disorders. A number of processes, including angiotensin-converting enzyme maladaptation, hypercoagulability, microvascular damage, and direct viral toxicity, may cause the etiology of post Covid-19 infection. Conclusion(s): Myocarditis in post Covid-19 condition is an uncommon but still possible condition that needs to be considered. It can be CTD mimickers;however, the symptoms must be closely monitored.Copyright © 2023

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.

Intentional Taxus Baccata Ingestion Presenting with Cardiogenic Shock and Ventricular Tachycardia

Background The prevalence of anxiety and depression has increased following the COVID pandemic. Young women are disproportionally at risk of suicidal behaviors. Ingestion of Taxus baccata (English Yew) may lead to cardiotoxicity and death. Intoxication is known to be resistant to standard treatments with no effective antidotes. Case A 20-year-old female with a history of major depressive disorder presented to our emergency department unresponsive in pulseless ventricular tachycardia (VT) (figure 1A). She underwent CPR and achieved ROSC, however, was persistently hypotensive despite multiple pressors and was subsequently placed on VA ECMO. Review of a home journal revealed a plan to ingest 50 grams of Yew with suicidal intent. Decision-making Taxoids have been reported to have similar properties to digoxin and therefore digoxin-specific FAB antibodies were administered. She was also started on amiodarone and lidocaine for management of VT. After 3 hours she converted into sinus rhythm and had no further episodes of VT. Her clinical course was complicated by severe LV dysfunction and dilation while on VA-ECMO necessitating placement of an LV impella. By day three, all mechanical support was weaned off and she had normalization of her EF. Patient was discharged to an inpatient psychiatry facility on day 7 of hospitalization. Conclusion Ingestion of English Yew with suicidal intent is rare but may cause cardiogenic shock and VT requiring aggressive hemodynamic support until the toxin is metabolized. [Formula presented]Copyright © 2023 American College of Cardiology Foundation

Randomized controlled study protocol: Shensong Yangxin in persistent atrial fibrillation after radiofrequency catheter ablation (SS-ADJUST)

Introduction: Atrial fibrillation (AF) is one of the most common forms of arrhythmia in the clinic. There are about 10 million AF patients in China, of which 1/3 are paroxysmal AF, and the remaining 2/3 are persistent or permanent AF. Long-term AF impairs cardiac function and leads to heart failure and thromboembolism. Moreover, AF increases the risk of mortality and ischemic stroke. Drug therapy and radiofrequency catheter ablation (RFCA) are still the mainstream treatment for AF patients. However, drug therapy has its drawbacks because of the high recurrence rate and side effects. Therefore, the current antiarrhythmic drugs could not meet all the clinical needs of patients with AF. RFCA is superior to antiarrhythmic drugs in maintaining sinus rhythm, improving symptoms and exercise tolerance, and improving quality of life. The role of RFCA in the treatment of persistent AF has gradually been recognized and affirmed. Although RFCA has been progressively used in the treatment of AF, there is still a high recurrence rate of AF after RFCA, especially in patients with persistent AF. Hence, it is meant to solve the high recurrence rate of AF after RFCA. Shensong Yangxin (SSYX) capsule has been proven to treat arrhythmia both in animal studies and clinical research. SSYX capsule could regulate multi-ion channels, improve cardiomyocyte metabolism and regulate autonomic nervous function. In addition, randomized, double-blind, multicenter clinical research indicated that the SSYX capsule exhibited good clinical efficacy in treating ventricular premature beats and paroxysmal AF. However, the effect of SSYX on recurrence after RFCA for patients with persistent AF remains unclear. High-level randomized controlled trials (RCTs) could offer clinicians high-quality evidence regarding the usage of SSYX capsule, especially in persistent AF patients who received RFCA. Hence, the RCTs aim to evaluate the effect of SSYX capsules on the prognosis in patients with persistent AF after RFCA through multicenter, double-blind RCTs. Method(s): This trial will be conducted with a total of 920 participants diagnosed with persistent AF who received RFCA. The participants will be randomized (1:1) into groups receiving either SSYX or Placebo for 1 year. The primary endpoint includes the recurrence of AF within 1 year after RFCA. The secondary outcome measures include changes of AF load at 3 months, 6 months, 9 months, and 1 year after treatment, the time of first atrial flutter/AF, the incidence of cardioversion 1 year after treatment, changes of transthoracic echocardiographic parameters 1 year after treatment, the incidence of stroke and thromboembolism at 6 months and 1 year after treatment, the score of SF-36 within 1 year after treatment. Application: The trial is ongoing. The trial started in September 2019 and recruiting patients. Data collection will be completed after all participants have completed the treatment course and follow-up assessments (expected in 2022, pending COVID-19). Next Steps/Future: The SS-ADJUST study is a randomized control study of TCM in persistent AF after RFCA. It will determine the place of SSYX capsule as a new treatment approach and provide additional and innovative information regarding TCM and the specific use of SSYX in persistent AF after RFCA.

Association of electrocardiographic abnormalities with in-hospital mortality in adult patients with COVID-19 infection

Objectives: The study aims to determine the association between electrocardiographic abnormalities and in-hospital mortality of patients with Coronavirus Disease 2019 (COVID-19) infection admitted in a tertiary hospital in the Philippines. Material(s) and Method(s): We conducted a retrospective study of confirmed COVID-19-infected patients. Demographic, clinical characteristics, and clinical outcomes were extracted from the medical records. Electrocardiographic analysis was derived from the 12-lead electrocardiogram (ECG) recorded upon admission. The frequencies and distributions of various clinical characteristics were described, and the ECG abnormalities associated with in-hospital mortality were investigated. Result(s): A total of 163 patients were included in the study, most were female (52.7%) with a median age of 55 years old. Sinus rhythm (40%), nonspecific ST and T wave changes (35%), and sinus tachycardia (22%) were the frequently reported ECG findings. The presence of any ECG abnormality was detected in 78.5% of patients and it was significantly associated with in-hospital mortality (p = 0.038). The analysis revealed a statistically significant association between in-hospital mortality and having atrial fibrillation or flutter (p = 0.002), supraventricular tachycardia (SVT) (p = 0.011), ventricular tachycardia (p = 0.011), third-degree atrioventricular block (AVB) (p = 0.011), T wave inversion (p = 0.005) and right ventricular hypertrophy (RVH) (p = 0.011). Conclusion(s): The presence of any ECG abnormality in patients with COVID-19 infection was associated with in-hospital mortality. ECG abnormalities that were associated with mortality were atrial fibrillation or flutter, SVT, ventricular tachycardia, third-degree AVB, T wave inversion, and RVH. Supporting Documents Association of electrocardiographic abnormalities with in-hospital mortality in adult patients with COVID-19 infection TARRANZA, Jannah Lee [1];RAMIREZ, Marcellus Francis [1,2];YAMAMOTO, Milagros [1] 1 Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines 2 Division of Electrophysiology, Section of Adult Cardiology, Department of Internal Medicine, University of Santo Tomas Hospital, Manila, Philippines.

The connection between heart rate variability (HRV), neurological health, and cognition: A literature review.

The heart and brain have bi-directional influences on each other, including autonomic regulation and hemodynamic connections. Heart rate variability (HRV) measures variation in beat-to-beat intervals. New findings about disorganized sinus rhythm (erratic rhythm, quantified as heart rate fragmentation, HRF) are discussed and suggest overestimation of autonomic activities in HRV changes, especially during aging or cardiovascular events. When excluding HRF, HRV is regulated via the central autonomic network (CAN). HRV acts as a proxy of autonomic activity and is associated with executive functions, decision-making, and emotional regulation in our health and wellbeing. Abnormal changes of HRV (e.g., decreased vagal functioning) are observed in various neurological conditions including mild cognitive impairments, dementia, mild traumatic brain injury, migraine, COVID-19, stroke, epilepsy, and psychological conditions (e.g., anxiety, stress, and schizophrenia). Efforts are needed to improve the dynamic and intriguing heart-brain interactions.

Pneumopericardium in COVID-19 Infection

Pneumopericardium is a rare medical condition that occurs following trauma, surgery, or other medical interventions. The presence of pneumopericardium after COVID-19 pneumonia has been reported in some cases, and it has been explained that most cases could be self-limited. Here, we describe a 51-year-old man afflicted by pneumopericardium with COVID-19 infection. The patient had pneumopericardium and massive pericardial effusions, necessitating surgical strategies such as pericardial windows. This case highlights the potential severity of COVID-19. We also suggest that cardiologists pay attention to the possibility of pneumopericardium in cases with COVID-19 infection. © 2023, Iranian Heart Association. All rights reserved.

Stop and smell the onions: Case report of delayed cardiotoxicity post ingestion of veratrum viride

Background: Vertatrum viride (false hellebore) is a perennial commonly found in eastern North America. The most common cause of exposure is misidentification when foraging for wild onion, or skunk cabbage. One regional poison center saw an increase in foraging-related poisonings during initial COVID-19 restrictions. The case report highlights severe delayed cardiac effects after ingestion of Veratrum viride in an otherwise healthy, young, female athlete. Case report: A 24-year-old female presented to an emergency room alongside family with complaints of nausea and vomiting that started 30 min after a meal consisting of foraged wild onion (Allium triccocum). Five others ate the same meal and noted similar symptoms. Vitals upon arrival (3 h post ingestion) are as described: HR 51, BP 88/52, Temp 36.7, RR 18 and O2 sat 100% on room air. The patient had no previous cardiac history and was athletic. Management included D5LR with K replacement, and dopamine infusion at 10mcg/kg/min. Dopamine was tapered slowly, down to 6 mcg/kg/min at 16.5 h. Vitals continued to be stable at 17.5 h post ingestion and dopamine was discontinued. The patient developed severe bradydysrhythmia 15 min later, consisting of complete heart block leading to prolonged sinus pause. She responded to 10 s of CPR with return of spontaneous circulation with a junctional escape rhythm which reverted back to sinus bradycardia. A repeat EKG was unremarkable. The dopamine infusion was reinstituted at 4 mcg/kg/min and continued until 26.5 h post ingestion. She was monitored an additional 9.5 h, and remained in sinus rhythm with mild complaints of dizziness that resolved before discharge. Discussion(s): Veratrum spp. toxicity is due to alkaloids found throughout the plant which cause sodium channel opening when bound to type 2 sodium channels. By increasing sodium ion influx during the resting potential and delaying inactivation to create a late sodium current, these alkaloids increase automaticity in conductive cells. This mechanism, paired with the Bezold-Jarisch reflex, is likely responsible for increased vagal tone leading to bradycardia, hypotension, sinus arrhythmia, and junctional escape rhythm. It is noteworthy that even 18 h post ingestion in a relatively stable patient with no significant cardiac history, cardiac arrest occurred just after treatment tapering. Clinicians should consider prolonged observation time in the setting of discontinuation of vasopressors. Conclusion(s): Both clinicians and amateur foragers should be aware of the risks associated with ingestion of Veratrum viride, especially during early spring when it more closely resembles wild onion. While uncommon, significant delayed cardiac effects are possible. Mistaking the plant for edible wild onions can be the difference between a delectable dinner, and a night in the ICU.

Hidden in plain sight: A case of arrhythmia and sudden cardiac failure masked by COVID-19 positivity

Background and Aim: Whilst most commonly recognised as a res-piratory pathogen, COVID-19 can also result in a variety of extrapulmonary manifestations including myocardial dysfunction and arrhythmia. We report a case of a 15 year old girl with repaired atrioventricular septal defect, presenting with arrhythmia and sud-den severe cardiac failure masked by COVID-19 positivity. Method(s): A 15 year old girl with repaired atrioventricular septal defect and tetralogy of Fallot, under regular follow up with asymp-tomatic moderate to severe atrioventricular valve dysfunction, pre-sented with one month's history of progressive breathlessness to her local hospital. Onset of illness coincided with typical COVID-19 symptoms;her family, attributing her deterioration to this, delayed seeking medical help. She was rapidly referred to our unit. The heart failure severity, which included diffuse dependent oedema, large pleural effusion and severe biventricular dysfunc-tion, could not be attributed to major valve function change. Moreover, deterioration had occurred rapidly without apparent ongoing cause, after extensive diagnostics. Tachyarrhythmia was suspected;initial adenosine challenge via peripheral vein was inconclusive. Diuretics, inotrope and empirical administration of amiodarone provided limited response;the patient was therefore ventilated, enabling further adenosine challenge via central line, which revealed atrial flutter. Shortly after conversion to sinus rhythm and pleural drainage, her biventricular function improved to near normal. Result(s): Redo surgery was undertaken. Firstly, this included mechanical valve replacement of left and right atrioventricular valves and ablation of the isthmus. Secondly, a permanent pace-maker was inserted a few days later. The patient made a quick and uneventful recovery and was discharged on day 10 with good biventricular function on minimal medical therapy and no symptoms. Conclusion(s): Our case highlights delayed presentation as a hidden effect of the COVID-19 pandemic, and that sudden deterioration in stable children with repaired congenital heart disease should prompt the clinician to exclude all reversible causes of de-stabili-sation, and in particular to maintain high suspicion of arrhythmia.

Life-threatening rhythm and conduction disorders by a child with MIS-C

Background and Aim: Cardiac involvement is seen in the majority of cases with multisystem inflammatory syndrome in children (MIS-C). Various rhythm and conduction disturbances, as well as repolarization abnormalities, have been described by more than 50% of the patients, while there are few cases with complete heart block or with asystole. Method(s): Case report Results: 8-year old girl presented with a 5-day history of fever, cough, headache, and abdominal pain. Because of the critical con-dition, with respiratory insufficiency and heart failure symptoms, the child was intubated and started on inotropic support. ECG showed complete AV-block with a ventricular rate of 75/min and with ST-T changes;echocardiography revealed dilated left ventricle with reduced contractility, CT-scan of the lungs showed bilateral pneumonia, the inflammatory markers were elevated, in combination with high troponin levels, and positive SARS-CoV2-IgG antibodies. The diagnosis MIS-C was made and treatment with immunoglobulins, antibiotics, corticosteroids, and anticoagulants was initiated. During the next 2 days, the cardiac function deteriorated further, and while still on mechanical ventilation and inotropic support, extreme bradycardia with a ventricular rate of 35/min was regis-tered, and the patient was indicated for temporary emergency pac-ing. Upon induction of anesthesia, the child became asystolic, requiring extensive resuscitation. After circulation recovery, the ECG showed nodal tachycardia with a heart rate of 140-170/min. A temporary transvenous pacemaker (PM) was inserted, and the patient was started on intravenous amiodarone which resulted in a slower ventricular rate of 70/min. 3 days later sinus rhythm was restored, with first-degree AV-block, which allowed removal of the PM 5 days after its insertion. Left ventricular dimensions were normalized and contractility remained low-normal (EF 56%). During the 6-month follow-up, the ECG and the Holter-monitoring showed sinus rhythm with first-degree AV-block. Magnetic resonance imaging (MRI) on day 15 of the hospital stay demonstrated scattered areas of myocarditis and ischemia predominantly in the left ventricle, as well as thickening of the basal septum. Six months later the MRI changes were reduced but still persistent. Conclusion(s): MIS-C can present with serious and life-threatening rhythm and conduction disturbances in children;this is why extensive cardiac monitoring is obligatory by all patients.

IDIOPATHIC TROPONEMIA AFTER TRANSCAROTID ARTERY REVASCULARIZATION

SESSION TITLE: Etiologies of Cardiovascular Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Troponin level (Tnl) is usually used as confirmation of acute myocardial infarction (AMI) and is a sensitive marker. It is usually increased within 2-3 hours after AMI. In most cases, increased in Tnl is associated with symptomatic chest pain, cardiac ischemia, chronic coronary syndromes, etc. It can also be elevated in other conditions without cardiac injuries, like critical illness: COVID infection, septic shock, acute stroke and burns. CASE PRESENTATION: A 72 y/o man with history of b/l internal carotid artery (ICA) stenosis (70% in R-ICA and 80-90% in L-ICA) underwent elective left trans-carotid artery revascularization (TCAR). He was transferred to ICU after an uneventful procedure, for monitoring. His history was significant for HTN, HLD, Meniere's disease, gout, prior CVA of L-frontal lacunar and R-PICA (posterior inferior cerebellar artery). Postop vitals: BP 114/60 mmHg, HR 65, RR 16, O2 sat 98%. Tnl increased to 1.95 and then declined (normal 0 - 0.4 ng/ml). He was AAOx4, and asymptomatic. Post-op serial EKGs: normal sinus rhythm with no ST/T wave changes. Echo: EF 60%, normal biventricular size and function. LDL <70, A1C 5.9, normal TSH, no CPK elevation. Other labs: normal, No new neurological deficits. He was continued on ASA, clopidogrel, metoprolol, amlodipine and lisinopril. His hospital stay was uneventful, and he was discharged on post-op day 3. DISCUSSION: Cardiac troponin complex has its distinct subunits according to their functions: highly conserved Ca2+ binding subunit (cTnC);actomyosin ATPase inhibitory subunit and tropomyosin binding subunit. They play the pivotal role in regulating myocardial muscle contraction and relaxation and demonstrate as sensitive biomarkers for the myocardial injuries. Interestingly, there are many other causes that lead to increased cardiac troponin level without remarkable myocardial injuries or ischemia. Elevated Tnl after TCAR procedure can also be due to its surgical complication of a chance of hypoperfusion during the procedure. Our patient's surgery was uneventful. In one randomized controlled trial, it is stated that the risk of having CVA and AMI is higher in carotid endarterectomy compared to revascularization in patients with carotid artery stenosis. Our patient did not have any post-op complication, and only had an idiopathic elevation of troponin. CONCLUSIONS: The role of Tnl plays an important role in confirmation of myocardial infarction or ischemia but it can be idiopathic. Unpublished data from our institution revealed no increase in troponin s/p TCAR after uneventful procedures. This is the first reported case presenting with elevated troponin level without any pertinent positive findings (EKG changes/symptoms). Maybe in uneventful TCAR procedure troponin should not be ordered? Reference #1: Defilippi, C.R., Tocchi, M., Parmar, R.J., Rosanio, S., Abreo, G., Potter, M.A., Runge, M.S., & Uretsky, B.F. (2000). Cardiac troponin T in chest pain unit patients without ischemic electrocardiographic changes: angiographic correlates and long-term clinical outcomes. Journal of the American College of Cardiology, 35 7, 1827-34. Reference #2: Gordon AM, Homsher E, Regnier M. Regulation of contraction in striated muscle. Physiol Rev. 2000 Apr;80(2):853-924. doi: 10.1152/physrev.2000.80.2.853. PMID: 10747208. Reference #3: Brott, T.G., Hobson, R.W., Howard, G., Roubin, G.S., Clark, W.M., Brooks, W., Mackey, A., Hill, M.D., Leimgruber, P.P., Sheffet, A.J., Howard, V.J., Moore, W.S., Voeks, J., Hopkins, L.N., Cutlip, D.E., Cohen, D.J., Popma, J.J., Ferguson, R.D., Cohen, S.N., Blackshear, J.L., Silver, F.L., Mohr, J.P., Lal, B.K., & Meschia, J.F. (2010). Stenting versus endarterectomy for treatment of carotid-artery stenosis. The New England journal of medicine, 363 1, 11-23. DISCLOSURES: No relevant relationships by Moses Bachan No relevant relationships by Zin Min Htet No relevant relationships by Z nobia Khan No relevant relationships by Zin Oo