Atrial fibrillation associated with COVID-19

One 56-year-old patient with no medical history presented after experiencing a fever and dyspnea for two days. He was treated with hydroxychloroquine and azithromycin for four days, but it made no impact and he was soon admitted to the ICU. The patient developed hemodynamically unstable atrial fibrillation (AF) on day 10 in the ICU.

“Systemic anticoagulation was initiated with IV heparin prior to emergent cardioversion,” the authors explained. “He converted to normal sinus rhythm (NSR), however, LVEF decreased to 40-45% and respiratory failure worsened, prompting cannulation for veno-venous extracorporeal membrane oxygenation (ECMO). Course was further complicated by gram negative bacteremia secondary to acute cholecystitis requiring percutaneous cholecystostomy and acute renal failure necessitating dialysis.”

The patient was later successfully cardioverted. He still remained hospitalized after 30 days, but he was extubated, decannulated from ECMO and taken off dialysis.

“While little is known about incidence of new-onset AF in patients with COVID-19, it has been associated with poor outcomes in critically ill patients,” Kochav and colleagues wrote. “As inflammation and its associated immune response are involved in the initiation and maintenance of AF, it is possible that anti-inflammatory therapies may be therapeutic, though this requires further study.”

Polymorphic ventricular tachycardia caused by COVID-19

One 64-year-old patient with a remote history of non-ischemic cardiomyopathy, paroxysmal AF and type 2 diabetes presented after two days of coughing and shortness of breath. The initial ECG showed NSR “with premature atrial and ventricular complexes” and a prolonged QTc. No significant bradycardia was present, and the patient was treated with a range of antibiotics that did include azithromycin. No hydroxychloroquine was administered due to the prolonged QTc.

On day two, the patient developed refractory hypoxemia and required intubation and mechanical ventilation. A classic long-short sequence occurred, followed by polymorphic ventricular tachycardia, and “multiple defibrillation attempts” occurred. Azithromycin treatment ended after a “subsequent shortening of QTc duration.” After 20 days of hospitalization, the patient is still mechanically ventilated.

“In this case, we highlight the arrhythmic risk faced amongst critically ill patients treated with potential COVID therapeutics which have QTc prolonging effects,” the authors wrote. “The patient developed torsades de pointes (TdP), likely precipitated by azithromycin in the setting of a baseline prolonged QT interval, which may have been related to previous cardiomyopathy, inherited ion-channel disorders, or possibly the effects of SARS-CoV-2 infection on the heart.”

If a patient develops TdP, the authors recommended electrical defibrillation as necessary, electrolyte repletion, modifications to the medications being administered and the consideration of lidocaine use.

“Health care workers (HCW) must don appropriate PPE in emergent situations such as defibrillation and provision of advanced life support,” the authors added. “The rapidity in which these patients can decline can make it quite challenging for HCW to prepare themselves with sufficient PPE before rushing to the bedside.”