Incidence of ventricular arrhythmias related to COVID infection and vaccination in patients with Brugada syndrome: Insights from a large Italian multicenter registry based on continuous rhythm monitoring.

INTRODUCTION: Brugada syndrome (BrS) has a dynamic ECG pattern that might be revealed by certain conditions such as fever. We evaluated the incidence and management of ventricular arrhythmias (VAs) related to COVID-19 infection and vaccination among BrS patients carriers of an implantable loop recorder (ILR) or implantable cardioverter-defibrillator (ICD) and followed by remote monitoring. METHODS: This was a multicenter retrospective study. Patients were carriers of devices with remote monitoring follow-up. We recorded VAs 6 months before COVID-19 infection or vaccination, during infection, at each vaccination, and up to 6-month post-COVID-19 or 1 month after the last vaccination. In ICD carriers, we documented any device intervention. RESULTS: We included 326 patients, 202 with an ICD and 124 with an ILR. One hundred and nine patients (33.4%) had COVID-19, 55% of whom developed fever. Hospitalization rate due to COVID-19 infection was 2.76%. After infection, we recorded only two ventricular tachycardias (VTs). After the first, second, and third vaccines, the incidence of non-sustained ventricular tachycardia (NSVT) was 1.5%, 2%, and 1%, respectively. The incidence of VT was 1% after the second dose. Six-month post-COVID-19 healing or 1 month after the last vaccine, we documented NSVT in 3.4%, VT in 0.5%, and ventricular fibrillation in 0.5% of patients. Overall, one patient received anti-tachycardia pacing and one a shock. ILR carriers had no VAs. No differences were found in VT before and after infection and before and after each vaccination. CONCLUSIONS: From this large multicenter study conducted in BrS patients, followed by remote monitoring, the overall incidence of sustained VAs after COVID-19 infection and vaccination is relatively low.

Clinical Characteristics of Shocks in Patients with implanted cardioverter defibrillator Following COVID-19 Infection (preprint)

Background and Aims: The relationship between SARS-CoV-2 infection and ICD shock remains unclear. We analyzed the characteristics of patients received shocks after SARS-CoV-2 infection to explore causes of these shocks to provide information for subsequent treatment. Methods: : We retrospectively analyzed data from seven patients who hospitalized the First People’s Hospital of Yunnan Province between December 2022 and January 2023 after experiencing ICD shock or ventricular arrhythmias following SARS-CoV-2 infection. We collected baseline information i.e., age and sex, device type, arrhythmia type, comorbidities, etc to analyze the causes of electrical shocks. Results: : All patients’ devices were implanted in our hospital. The patients’ mean age was 67±10 years. Four underwent implantation for primary prevention, and three for secondary prevention. These patients received 80 ICD shocks after SARS-CoV-2 infection, 71 (88.75%) nine (11.25%) of which were treatment for ventricular tachycardia and atrial fibrillation, respectively. There were 54 antitachycardia pacing(ATP) treatments, which forty-eight arrhythmic events were terminated through antitachycardia pacing and six not. Laboratory tests conducted upon admission revealed that six patients had blood potassium levels below 4.0 mmol/L. Five patients had blood calcium levels below 2.11 mmol/L. Four of seven patients had elevated troponin concentrations (0.030–0.297 ng/mL). All patients had significantly elevated N-terminal pro-B-type natriuretic peptide levels (608.8–25,758 pg/mL). Six patients had a QT interval of > 440 ms and a mean QT interval of 460±46 ms. Conclusion: SARS-CoV-2 infection may be associated with ICD shock. Clinicians should pay close attention to patients with implanted devices after SARS-CoV-2 infection and actively eliminate arrhythmogenic triggers to minimize the likelihood of ICD shock.

Ventricular Arrhythmia and COVID-19 Vaccine-associated Myocarditis.

17-year-old male presented with COVID-19 vaccine-associated myocarditis. Six months later, due to chest discomfort with exercise, the patient underwent an exercise stress test that revealed a 3-beat run of nonsustained ventricular tachycardia at 230 bpm at peak exercise. The long-term outcomes of COVID-19 vaccine-associated myocarditis are unclear. This patient had nonsustained ventricular tachycardia over 6 months after diagnosis.

Recurring episodes of bundle branch reentry ventricular tachycardia due to aortitis preceded by SARS-CoV-2 infection: a case report.

BACKGROUND: SARS-CoV-2 may trigger both vasculitis and arrhythmias as part of a multisystem inflammatory syndrome described in children as well as in adults following COVID-19 infection with only minor respiratory symptoms. The syndrome denotes a severe dysfunction of one or more extra-pulmonary organ systems, with symptom onset approximately 2-5 weeks after the COVID-19 infection. In the present case, a seemingly intractable ventricular tachycardia preceded by SARS-CoV2 infection was only managed following the diagnosis and management of aortitis. CASE PRESENTATION: A 69-year-old woman was hospitalized due to syncope, following a mild COVID-19 infection. She presented with paroxysmal atrial fibrillation and intermittent ventricular tachycardia interpreted as a septum-triggered bundle branch reentry ventricular tachycardia, unaffected by amiodaron, lidocaine and adenosine. A CT-scan revealed inflammation of the aortic arch, extending into the aortic root. In the following days, the tachycardia progressed to ventricular storm with intermittent third-degree AV block. A temporary pacemaker was implanted, and radiofrequency ablation was performed to both sides of the ventricular septum after which the ventricular tachycardia was non-inducible. Following supplemental prednisolone treatment, cardiac symptoms and arrythmia subsided, but recurred after tapering. Long-term prednisolone treatment was therefore initiated with no relapse in the following 14 months. CONCLUSION: We present a rare case of aortitis complicated with life-threatening ventricular tachycardia presided by Covid-19 infection without major respiratory symptoms. Given a known normal AV conduction prior to the COVID-19 infection, it seems likely that the ensuing aortitis in turn affected the septal myocardium, enabling the reentry tachycardia. Generally, bundle branch reentry tachycardia is best treated with radiofrequency ablation, but if it is due to aortitis with myocardial affection, long-term anti-inflammatory treatment is mandatory to prevent relapse and assure arrhythmia control. Our case highlights importance to recognize the existence of the multisystem inflammatory syndrome in adults (MIS-A) following COVID-19 infection in patients with alarming cardiovascular symptoms. The case shows that the early use of an CT-scan was crucial for both proper diagnosis and treatment option.

Difficulties in diagnosis of SARS-CoV-2 myocarditis in an adolescent.

OBJECTIVES: We present an adolescent with cardiogenic shock due to ventricular tachycardia 2 weeks after SARS-CoV-2 infection. Acute myocarditis or myocardial dysfunction is associated with SARS-CoV-2 infection, but diagnosis may be difficult, even including endomyocardial biopsy. CASE REPORT: A 15-year-old healthy adolescent was admitted to our hospital 2 weeks after SARS-CoV-2 infection with cardiogenic shock due to ventricular tachycardia. After cardioversion, antiarrhythmic treatment, ventilation, and inotropic support, the severely reduced myocardial function recovered completely within 2 weeks. Cardiac magnetic resonance imaging and cardiac catheterisation including right ventricular endomyocardial biopsy revealed an increased number of CD68+ macrophages in the myocardium, but nested (RT-) polymerase chain reaction (PCR) investigations revealed no viral or bacterial DNA/RNA. DISCUSSION: SARS-CoV-2 infection may be associated with myocarditis leading to life-threatening arrhythmia and severe myocardial systolic and diastolic dysfunction, which may be short lasting and completely recover. Although former SARS-Cov-2 infection might suggest SARS-CoV-2-associated myocarditis, definite histological diagnosis including nested PCR investigations remains difficult.

Impact of coronavirus disease 19 outbreak on arrhythmic events and mortality among implantable cardioverter defibrillator patients followed up by remote monitoring: a single center study from the Veneto region of Italy.

BACKGROUND: The 2020 severe acute respiratory syndrome coronavirus 2 outbreak entailed reduced availability of traditional (in-office) cardiology consultations. Remote monitoring is an alternative way of caring that may potentially mitigate the negative effects of the epidemic to the care of cardiovascular diseases. We evaluated the outcome of implantable cardioverter defibrillator (ICD) carriers followed up remotely in 2020 (epidemic period) versus 2019 (control). METHODS: We included all patients with an ICD who remained remotely monitored from the beginning to the end of each year. The combined end point included: new-onset atrial fibrillation; sustained ventricular tachycardia >170 bpm without ICD intervention; appropriate ICD intervention (either shock or antitachycardia pacing); any-cause death. Multiple events in the same patients were counted separately if occurring ≥48 h apart. RESULTS: In 2020, 52 end points occurred in 37 of 366 (10%) ICD carriers [0.14/patient (95% confidence interval [CI] = 0.11-0.19)] versus 43 end points in 32 of 325 (10%) ICD carriers in 2019 [0.13/patient (95% CI = 0.10-0.18) P  = 0.75]. There was no difference between the distribution of any individual end point in 2020 versus 2019 although a nonsignificant mortality increase was observed (from 2.8% to 4.6%, P  = 0.19). The lowest weekly event rate occurred during the national lock down in spring 2020 but a similar trend occurred also in 2019 suggesting that the effect may not be linked to social distancing measures. CONCLUSIONS: We did not observe an increase in a combined end point including arrhythmic events and mortality in ICD carriers who were remotely monitored in 2020, compared to 2019, despite the negative impact of the coronavirus disease 2019 outbreak on the healthcare system.

Primary hypothyroidism with an episode of ventricular tachycardia in a patient with COVID-19: A case report.

RATIONALE: Coronavirus disease 2019 (COVID-19) is a systemic disease with major clinical manifestations in the respiratory system. However, thyroid involvement has also been reported. We present a case of hypothyroidism with ventricular tachycardia following diagnosis with COVID-19. PATIENT CONCERNS: A 77-year-old man was admitted to the isolation ward due to COVID-19. After respiratory support and medical treatment, the patient was successfully weaned off the ventilator. However, an episode of short-run ventricular tachycardia was detected, and primary hypothyroidism was also diagnosed. DIAGNOSIS: Ventricular tachycardia was detected by electrocardiography. INTERVENTIONS: Intravenous amiodarone administration and oral levothyroxine replacement. OUTCOMES: No arrhythmia detected following treatment. LESSONS: Awareness of the association between hypothyroidism and COVID-19 is important in preventing possible complications.

Ventricular Tachycardia or Fibrillation Storm in Coronavirus Disease (preprint)

Ventricular tachycardia (VT) or ventricular fibrillation (VF) storm associated with severe acute respiratory syndrome coronavirus-2 infection is a potentially fatal complication; the correlation of these 2 disorders, however, has not been well studied. This retrospective case series examined outcomes of 2 patients who were admitted for repeated implantable cardioverter-defibrillator shocks with or without syncope and observed to have VT/VF storms with COVID-19. Mechanisms of VT/VF storms in COVID-19 are multifactorial including myocarditis, systemic inflammation, hyperadrenergic state, hemodynamic instability, hypoxia, acidosis, and proarrhythmic drugs. A higher incidence of VT/VF storm is observed in patients with comorbidities and those requiring critical care, with some studies reporting increased mortality. In our cohort, 1 of the 2 patients succumbed to the complications from COVID-19 and the other patient was discharged to home in stable condition. Monitoring of life-threatening arrhythmias in the setting of COVID-19 may need to be adopted to prevent morbidity and mortality.

Right Ventricular Outflow Tract Tachycardia in a COVID-19 Patient: A Case Report and Review of the Literature (preprint)

Objectives: The novel Coronavirus (SARS-CoV2) adversely affects cardiac status and may cause arrhythmias. The objective of this study is to describe the case of a 41 year-old female presenting to the emergency department with Right ventricular outflow tract (RVOT) ventricular tachycardia; as well as to appraise and compare etiologies proposed in the literature with our case. Methods: The study design is a case report and review of the literature. A PubMed/Medline search was conducted including studies published in peer-reviewed journals between December, 2019 and November, 2020. Papers discussing the relationship between COVID-19 and cardiac arrhythmias were included, excluding the pediatric population and papers with major confounding factors to the predisposition of cardiac arrhythmias. Results: 6 papers were included in the qualitative synthesis. These papers discussed different mechanisms by which COVID-19 can cause arrhythmias. These results were compared with the findings in our case in an attempt to better understand the etiology behind our case of RVOT-VT. Proposed etiologies included ACE2-mediated direct damage of cardiomyocytes, raised serum CRP levels, and raised systemic inflammatory markers and activation of the Ca2+/Calmodulin protein kinase I. Conclusion: The lack of associated comorbidities and risk factors in our patient highlights the unique challenge of identifying the clinical sequelae of COVID-19. Proposed pathophysiologies in the literature were not applicable to our case, highlighting the need for clinical monitoring in patients, and the need for further research on the topic.

Ventricular tachycardia from myocarditis following COVID-19 vaccination with tozinameran (BNT162b2, Pfizer-BioNTech).

To combat the coronavirus disease 2019 (COVID-19) pandemic, many countries have started population vaccination programs using messenger ribonucleic acid (mRNA) vaccines. With the widespread use of such vaccines, reports are emerging worldwide, of the vaccine's association with the development of myocarditis. Younger men are more likely to develop postvaccine myocarditis, which usually presents as self-limiting chest pain within a week after the second dose. We present a case of myocarditis following vaccination with tozinameran (BNT162b2, Pfizer-BioNTech), which presented late, with ventricular tachycardia (VT) reduced left ventricular ejection fraction (LVEF).

Usefulness of long-term telemetric electrocardiogram monitoring in the diagnosis of tachycardia in children with a medical history of palpitations.

BACKGROUND: In children, palpitations, which may result from a life­threatening tachyarrhythmia, are one of the most common causes of cardiac visits and hospitalizations. Effective diagnosis is essential in this population of patients. AIMS: This study aimed to assess the usefulness of long­term telemetric electrocardiograms compared with Holter monitoring in the diagnostic workup in children with palpitations. METHODS: A total of 350 children with undocumented palpitations were examined in a multicenter study. In 167 patients (47.7%), the TELE group, month­long continuous telemetric electrocardiogram monitoring (using the PocketECG system) was performed. In 183 patients (52.3%), the HOLT group, 24­hour Holter electrocardiography was carried out and repeated after a month if tachyarrhythmia was not recorded. RESULTS: A total of 152 children (43.4%) reported palpitations, and 36.2% of them had sinus tachycardia during palpitations. Tachyarrhythmias were recorded in 68 patients (40.7%) in the TELE group and in 7 (3.8%) in the HOLT group after the second examination (P <0.001); the mean time to record tachycardia was 15.8 (8.7) days versus 25.4 (11.1) days (P = 0.004). In the TELE group, we noted a greater number of children with palpitations during recording (62.9% vs 18%), tachycardia with normal QRS complexes (21.6% vs 1.6%), ventricular tachycardia (11.4% vs 0.5%), and asymptomatic arrhythmias than in the HOLT group. CONCLUSIONS: In children, long­term telemetric electrocardiogram monitoring using the PocketECG system is well tolerated and has a high diagnostic efficacy. In young patients with palpitations, telemetric cardiac monitoring lasting up to a month increased the number of patients with recorded tachyarrhythmia by almost 10-fold compared with the analysis of 2 Holter electrocardiograms. We found that a large number of children have asymptomatic cardiac arrhythmias.

Diagnostic Difficulties in a Case of Fetal Ventricular Tachycardia Associated with Neonatal COVID Infection: Case Report.

The clinical course of COVID in the pediatric population is considered to be much milder when compared to adults; however, the occurrence of severe and fatal forms of the disease in children is non-negligible, especially in patients with comorbidities such as prematurity or cardiac disease. We report a case of a newborn with sotalol-controlled fetal ventricular tachycardia, who was postnatally diagnosed with COVID infection. The myocardial injury was sustained on the basis of pericardial effusion, left ventricular dysfunction, rapid progression to coronary artery dilation, and an arrhythmic storm. We believe that, in our case, there is a significant overlap between fetal ventricular tachycardia, associated with impaired left ventricular function, and COVID infection, diagnosed after birth; both factors contribute to the myocardial dysfunction with a fulminant clinical evolution. To our knowledge, this is the first case describing neonatal myocardial dysfunction associated with SARS-CoV infection complicating the clinical course of rare fetal tachyarrhythmia.

COVID-19 and Cardiac Arrhythmias.

Since the coronavirus disease (COVID-19) pandemic spread unrelentingly all over the world, millions of cases have been reported. Despite a high number of asymptomatic cases, the course of the disease can be serious or even fatal. The affection of the myocardium, called myocardial injury, is caused by multiple triggers. The occurrence of cardiac arrhythmias in COVID-19 patients with myocardial involvement and a critical course is common. In this review, potential mechanisms, incidence, and treatment options for cardiac arrhythmias in COVID-19 patients will be provided by performing a literature research in MESH database and the National Library of Medicine. Common cardiac arrhythmias in COVID-19 patients were sinus tachycardia, atrial fibrillation (AF), ventricular tachycardia (VT), ventricular fibrillation (VF), atrioventricular block, sinusoidal block or QTc prolongation. AF was the most common heart rhythm disorder. About 10% of COVID-19 patients develop new-onset AF and 23 to 33% showed recurrence of AF in patients with known AF. One retrospective trial revealed the incidence of VT or VF to be 5.9% in hospitalized patients. Both AF and VT are clearly associated with worse outcome. Several mechanisms such as hypoxia, myocarditis, myocardial ischemia, or abnormal host immune response, which induce cardiac arrhythmias, have been described. The effect of QT-prolonging drugs in inducing cardiac arrhythmias has become mitigated as these medications are no longer recommended. Acute management of cardiac arrhythmias in COVID-19 patients is affected by the reduction of exposure of health care personnel. More prospective data are desirable to better understand pathophysiology and consecutively adapt management.

Lithium toxicity at therapeutic doses as a fallout of COVID-19 infection: a case series and possible mechanisms.

Lithium, a mood stabilizer used in the treatment of bipolar disorder is known for its anti-inflammatory properties with the discussion of its potential use in COVID-19 infection. The SARS-CoV-2 virus causing COVID-19 infection is known to enter the target cells through angiotensin converting enzyme-2 receptors present in abundance in the lung and renal tissue. Recent research supports the evidence for direct renal injury by viral proteins. Here we report two patients with bipolar disorder presenting with lithium toxicity in the presence of COVID-19 infection. Two patients with bipolar disorder, maintaining remission on lithium prophylaxis, presented to the psychiatric emergency with recent-onset fever and altered sensorium. Both the patient's investigations revealed lithium toxicity, elevated serum creatinine, urea and inflammatory markers. Hypernatremia, hyperkalaemia, and hyperchloremia were seen in one patient. Lithium and other psychotropic medications were stopped immediately, and COVID-19 treatment was initiated. Patient with clinical signs of lithium toxicity, hypernatremia, hyperkalaemia, and hyperchloremia developed ventricular tachycardia. He survived and regained consciousness after 2 weeks of aggressive conservative management. However, another patient died of acute respiratory failure on day 3. Possible direct infection of the kidney by SARS-CoV-2 viral proteins can manifest with acute kidney injury and lithium toxicity among patients on long-term lithium therapy. Health professionals treating COVID-19 infection among individuals on lithium therapy should be aware of the possibility of lithium toxicity in the background of renal injury.

J-waves in acute COVID-19: A novel disease characteristic and predictor of mortality?

BACKGROUND: J-waves represent a common finding in routine ECGs (5-6%) and are closely linked to ventricular tachycardias. While arrhythmias and non-specific ECG alterations are a frequent finding in COVID-19, an analysis of J-wave incidence in acute COVID-19 is lacking. METHODS: A total of 386 patients consecutively, hospitalized due to acute COVID-19 pneumonia were included in this retrospective analysis. Admission ECGs were analyzed, screened for J-waves and correlated to clinical characteristics and 28-day mortality. RESULTS: J-waves were present in 12.2% of patients. Factors associated with the presence of J-waves were old age, female sex, a history of stroke and/or heart failure, high CRP levels as well as a high BMI. Mortality rates were significantly higher in patients with J-waves in the admission ECG compared to the non-J-wave cohort (J-wave: 14.9% vs. non-J-wave 3.8%, p = 0.001). After adjusting for confounders using a multivariable cox regression model, the incidence of J-waves was an independent predictor of mortality at 28-days (OR 2.76 95% CI: 1.15-6.63; p = 0.023). J-waves disappeared or declined in 36.4% of COVID-19 survivors with available ECGs for 6-8 months follow-up. CONCLUSION: J-waves are frequently and often transiently found in the admission ECG of patients hospitalized with acute COVID-19. Furthermore, they seem to be an independent predictor of 28-day mortality.