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.

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 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).

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.

Cardiac Arrhythmias in Patients with COVID-19. / Arritmias Cardíacas em Pacientes com COVID-19.

BACKGROUND: The coronavirus disease 2019 (COVID-19) is associated with cardiovascular clinical manifestations, including cardiac arrhythmias. OBJECTIVE: To assess the incidence of cardiac arrhythmias (atrial tachyarrhythmia, bradyarrhythmia, and sustained ventricular tachycardia) and cardiac arrest (CA) in a cohort of patients hospitalized with COVID-19 in a tertiary university-affiliated hospital. METHODS: Cohort study with retrospective analysis of electronic medical records. For comparison between groups, a value of p <0.05 was considered statistically significant. RESULTS: We included 241 consecutive patients diagnosed with COVID-19 (mean age, 57.8 ± 15.0 years; 51.5% men; 80.5% white), 35.3% of whom received invasive mechanical ventilation (MV). The overall mortality was 26.6%, being 58.8% among those on MV. Cardiac arrhythmias were identified in 8.7% of the patients, the most common being atrial tachyarrhythmia (76.2%). Patients with arrhythmias had higher mortality (52.4% versus 24.1%, p = 0.005). On multivariate analysis, only the presence of heart failure (HF) was associated with a higher risk of arrhythmias (hazard ratio, 11.9; 95% CI: 3.6-39.5; p <0.001). During hospitalization, 3.3% of the patients experienced CA, with a predominance of non-shockable rhythms. All patients experiencing CA died during hospitalization. CONCLUSIONS: The incidence of cardiac arrhythmias in patients admitted with COVID-19 to a Brazilian tertiary hospital was 8.7%, and atrial tachyarrhythmia was the most common. Presence of HF was associated with an increased risk of arrhythmias. Patients with COVID-19 experiencing CA have high mortality.

FUNDAMENTO: A doença pelo novo coronavírus (COVID-19) está associada a manifestações clínicas cardiovasculares, incluindo a ocorrência de arritmias cardíacas. OBJETIVOS: Avaliar a incidência de arritmias cardíacas (taquiarritmia atrial, bradiarritmia e taquicardia ventricular sustentada) e de parada cardiorrespiratória (PCR) em uma coorte de pacientes internados com COVID-19 em hospital universitário terciário. MÉTODOS: Estudo de coorte retrospectivo realizado por meio de revisão dos registros de prontuário médico. Para comparação entre os grupos, foi considerado como estatisticamente significativo valor de P < 0,05. RESULTADOS: Foram incluídos 241 pacientes consecutivos com diagnóstico de COVID-19 (idade média, 57,8 ± 15,0 anos; 51,5% homens; 80,5% de raça branca) e 35,3% com necessidade de ventilação mecânica invasiva (VM). A mortalidade geral foi de 26,6%, sendo de 58,8% entre aqueles em VM. Arritmias cardíacas ocorreram em 8,7% dos pacientes, sendo a mais comum taquiarritmia atrial (76,2%). Pacientes com arritmias apresentaram maior mortalidade, 52,4% versus 24,1% (p=0,005). Em análise multivariada, apenas a presença de insuficiência cardíaca foi associada a maior risco de arritmias ( hazard ratio , 11,9; IC 95%: 3,6-39,5; p<0,001). Durante a internação, 3,3% dos pacientes foram atendidos em PCR, com predomínio de ritmos não chocáveis. Todos os atendidos em PCR evoluíram com óbito durante a internação. CONCLUSÃO: A incidência de arritmias cardíacas em pacientes internados com COVID-19 em hospital terciário brasileiro foi de 8,7%, sendo a mais comum taquiarritmias atrial. A presença de insuficiência cardíaca foi associada a maior risco de arritmias. Pacientes com COVID-19 atendidos em PCR apresentam elevada mortalidade.

Ventricular tachycardia with epicardial and pericardial fibrosis 6 months after resolution of subclinical COVID-19: a case report.

BACKGROUND: Coronavirus disease 2019 (COVID-19) has been shown to have extensive effects on the cardiovascular system. Its long-term cardiac manifestations, however, remain unclear. CASE PRESENTATION: We report the case of a Caucasian patient with a mild and self-limited presentation of COVID-19, with subsequent development, months later, of exertional dyspnea and non-sustained ventricular tachycardia, long after resolution of his illness and after returning to aerobic exercise. The patient had normal screening tests including electrocardiogram (ECG) and echocardiogram 4 months after his illness. Cardiac magnetic resonance imaging demonstrated epicardial and pericardial fibrosis of the right ventricle free wall and outflow tract and the pericardium over the anterior wall, 6 months following the initial infection. First abnormal ECG was recorded at month 7 following illness. CONCLUSIONS: This case suggests an insidious and possible long-term cardiac involvement and reflects the challenges in traditional workups and screening modalities in identifying cardiac involvement in COVID-19.

Sustained ventricular tachycardia in a paediatric patient with acute COVID-19 myocarditis.

Although rare, children with active coronavirus disease 2019 are at risk of developing malignant arrhythmia. Herein, we present the first paediatric case of refractory ventricular tachycardia from acute fulminant myocarditis secondary to acute COVID-19 infection. This 5-year-old boy required venoarterial extracorporeal membrane oxygenation support, but made a complete recovery without significant morbidity.

Severe cortical damage associated with COVID-19 case report.

Symptoms of COVID-19, as reported during the SARS-CoV-2 pandemic in 2019-2020, are primarily respiratory and gastrointestinal, with sparse reports on neurological manifestations. We describe the case of a 17-year old female with Cornelia de Lange syndrome and well controlled epilepsy, who sustained significant cortical injury during a COVID-19 associated multi-inflammatory syndrome.

Cardiac arrhythmias in hospitalized patients with COVID-19: A prospective observational study in the western United States.

Arrhythmias have been reported frequently in COVID-19 patients, but the incidence and nature have not been well characterized. Patients admitted with COVID-19 and monitored by telemetry were prospectively enrolled in the study. Baseline characteristics, hospital course, treatment and complications were collected from the patients' medical records. Telemetry was monitored to detect the incidence of cardiac arrhythmias. The incidence and types of cardiac arrhythmias were analyzed and compared between survivors and non-survivors. Among 143 patients admitted with telemetry monitoring, overall in-hospital mortality was 25.2% (36/143 patients) during the period of observation (mean follow-up 23.7 days). Survivors were less tachycardic on initial presentation (heart rate 90.6 ± 19.6 vs. 99.3 ± 23.1 bpm, p = 0.030) and had lower troponin (peak troponin 0.03 vs. 0.18 ng/ml. p = 0.004), C-reactive protein (peak C-reactive protein 97 vs. 181 mg/dl, p = 0.029), and interleukin-6 levels (peak interleukin-6 30 vs. 246 pg/ml, p = 0.003). Sinus tachycardia, the most common arrhythmia (detected in 39.9% [57/143] of patients), occurred more frequently in non-survivors (58.3% vs. 33.6% in survivors, p = 0.009). Premature ventricular complexes occurred in 28.7% (41/143), and non-sustained ventricular tachycardia in 15.4% (22/143) of patients, with no difference between survivors and non-survivors. Sustained ventricular tachycardia and ventricular fibrillation were not frequent (seen only in 1.4% and 0.7% of patients, respectively). Contrary to reports from other regions, overall mortality was higher and ventricular arrhythmias were infrequent in this hospitalized and monitored COVID-19 population. Either disease or management-related factors could explain this divergence of clinical outcomes, and should be urgently investigated.

Incidence and treatment of arrhythmias secondary to coronavirus infection in humans: A systematic review.

BACKGROUND: The coronavirus disease 2019 (COVID-19) pandemic has affected millions of people worldwide resulting in significant morbidity and mortality. Arrhythmias are prevalent and reportedly, the second most common complication. Several mechanistic pathways are proposed to explain the pro-arrhythmic effects of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. A number of treatment approaches have been trialled, each with its inherent unique challenges. This rapid systematic review aimed to examine the current incidence and available treatment of arrhythmias in COVID-19, as well as barriers to implementation. METHODS: Our search of scientific databases identified relevant published studies from 1 January 2000 until 1 June 2020. We also searched Google Scholar for grey literature. We identified 1729 publications of which 1704 were excluded. RESULTS: The incidence and nature of arrhythmias in the setting of COVID-19 were poorly documented across studies. The cumulative incidence of arrhythmia across studies of hospitalised patients was 6.9%. Drug-induced long QT syndrome secondary to antimalarial and antimicrobial therapy was a significant contributor to arrhythmia formation, with an incidence of 14.15%. Torsades de pointes (TdP) and sudden cardiac death (SCD) were reported. Treatment strategies aim to minimise this through risk stratification and regular monitoring of corrected QT interval (QTc). CONCLUSION: Patients with SARS-CoV-2 are at an increased risk of arrhythmias. Drug therapy is pro-arrhythmogenic and may result in TdP and SCD in these patients. Risk assessment and regular QTc monitoring are imperative for safety during the treatment course. Further studies are needed to guide future decision-making.

Prevention of Ventricular Arrhythmia and Sudden Cardiac Death in COVID-19 Patients.

Since the first case was reported at the end of 2019, COVID-19 has spread throughout the world and has become a pandemic. The high transmission rate of the virus has made it a threat to public health globally. Viral infections may trigger acute coronary syndromes, arrhythmias, and exacerbation of heart failure, due to a combination of effects including significant systemic inflammatory responses and localized vascular inflammation at the arterial plaque level. Indonesian clinical practice guideline stated that (hydroxy)chloroquine alone or in combination with azithromycin may be used to treat for COVID-19. However, chloroquine, hydroxychloroquine, and azithromycin all prolong the QT interval, raising concerns about the risk of arrhythmic death from individual or concurrent use of these medications. To date, there is still no vaccine or specific antiviral treatment for COVID-19. Therefore, prevention of infection in people with cardiovascular risk and mitigation of the adverse effects of treatment is necessary.

Prolonged QT Interval in a Patient With Coronavirus Disease-2019: Beyond Hydroxychloroquine and Azithromycin.

Recent reports have suggested an increased risk of QT prolongation and subsequent life-threatening ventricular arrhythmias, particularly torsade de pointes, in patients with coronavirus disease-2019 (COVID-19) treated with hydroxychloroquine and azithromycin. In this article, we report the case of a 75-year-old female with a baseline prolonged QT interval in whom the COVID-19 illness resulted in further remarkable QT prolongation (>700 ms), precipitating recurrent self-terminating episodes of torsade de pointes that necessitated temporary cardiac pacing. Despite the correction of hypoxemia and the absence of reversible factors, such as adverse medication effects, electrolyte derangements, and usage of hydroxychloroquine/azithromycin, the QT interval remained persistently prolonged compared with the baseline with subsequent degeneration into ventricular tachycardia and death. Thus, we highlight that COVID-19 illness itself can potentially lead to further prolongation of QT interval and unmask fatal ventricular arrhythmias in patients who have a prolonged QT and low repolarization reserve at baseline.

Interpretation of arrhythmogenic effects of COVID-19 disease through ECG.

OBJECTIVE: We aimed to detect the malignant arrhythmic potential of COVID-19 with surface electrocardiographic (ECG) markers. MATERIAL AND METHOD: Of the ECG parameters PR, QT, QTc, QTd, TPe, and Tpe/QTc were measured in 51 COVID-19 patients and 40 in control subjects. RESULTS: Compared to control group mean QTc (410.8 ± 24.3 msec vs. 394.6 ± 20.3 msec, p < .001) and Tpe/QTc (0.19 ± 0.02 vs. 0.18 ± 0.04, p = .036) and median QTd (47.52 vs. 46.5) values were significantly higher in COVID-19 patients. Troponin levels were significantly correlated with heart rate (r = 0.387, p = .006) but not with ECG parameters. CONCLUSION: Several ventricular arrhythmia surface ECG predictors including QTc, QTd, and Tpe/QTc are increased in COVID-19 patients. Since medications used in COVID-19 patients have the potential to affect these parameters, giving importance to these ECG markers may have a significant contribution in decreasing disease-related arrhythmias.