<div>Acute heart failure and complete AV block in a patient with severe
Covid-19 pneumonia.</div><div>Authors.</div><div>Rodríguez-Zanella Hugo MD</div><div>Echocardiography Department</div><div>National Institute of Cardiology of Mexico, Ignacio Chavez</div><div>Gutiérrez-Villaseñor Alan O.MD</div><div>Intensive care Unit, Medica Sur, Clinical Foundation</div><div>Institution: Medica Sur, Clinical Foundation</div><div>Romero-González Juan P. MD</div><div>Intensive care Unit, Medica Sur, Clinical Foundation</div><div>Adriana Torres-Machorro MD</div><div>Surgery Department</div><div>National Institute of Cardiology of Mexico, Ignacio Chavez</div><div>Ana Karla Tobias Morales MD</div><div>Echocardiography Department</div><div>National Institute of Cardiology of Mexico, Ignacio Chavez</div><div>Corresponding Author.</div><div>Silvio A, ÑamendysSilva MD, MSc, FCCP,FCCM</div><div>Address: Instituto Nacional de Cancerologia and Instituto Nacional de
Ciencias Medicas y Nutricion Salvador Zubiran, 14080, Mexico City,
Mexico</div><div>Email:<i>snamendys@incan.edu.mx</i></div><div>Contact: +525556280400</div><div>Abstract</div><div>We present the challenging case of a patient with severe COVID-19
pneumonia complicated with cardiogenic shock and refractory complete AV
block. The patient presented with wall motion abnormalities on
echocardiography, and cardiac magnetic resonance revealed finding
compatible with myocarditis. Myocardial injury may occur in up to 31%
of patients with Covid-19 pneumonia and has been related to increased
mortality. However, whether myocardial injury might result from direct
damage from the virus or related to complications of the disease is
still unclear. Although myocarditis is not common in COVID patients, it
should be considered as a possible diagnosis.</div><div>Keywords: Cardiomyopathies, Heart Failure, Echocardiography, Magnetic
Resonance</div><div>We describe a patient with severe COVID pneumonia, with acute heart
failure, cardiogenic shock, and complete AV Block in a critical care
unit designated to treat Covid-19 patients. Myocardial injury may occur
in up to 31% of patients with Covid-19 pneumonia and has been related
to increased mortality (1,2). Whether myocardial injury might result
from direct damage from the virus or related to complications of the
disease is still unclear.</div><div>A 65 years old male with a history of diabetes mellitus, presented to
the emergency department with shortness of breath, fever, cough, and low
oxygen saturation (SPO2 87%). Thoracic CT was performed, demonstrating
typical Covid-19 findings. (Figure 1 panel C) Confirmatory RT-PCR and
diagnosis of Severe acute respiratory syndrome coronavirus 2
(SARS-CoV-2) was made on April 20. PCR testing for other respiratory
viruses was negative. Symptomatic treatment and thromboprophylaxis with
low molecular weight heparin were instaurated.</div><div>Two days later, the patient progressed to hypoxemic respiratory failure
requiring mechanical ventilation. The patient was admitted to the
intensive care unit, hemodynamically stable, and responded well to
mechanical ventilation with lung protection. The patient was doing
better, and weaning protocol was already planned. However, on April 30,
the patient suddenly presented with hypotension and bradycardia. A
surface ECG showed complete AV Block, with left bundle branch block
(Figure 1 panel A). The patient was started on vasopressors, and a
temporary pacemaker was placed. Initial high sensitivity troponin was
elevated (1730 ng/ml), and BNP was normal, left ventricular function was
reduced, and wall motion abnormalities in the apical segments were found
(Figure 1 panel D and Video 1).</div><div>Differentials included Takotsubo cardiomyopathy, acute myocarditis, and
acute coronary syndrome. Because of the previous risk factors and
elevated high sensitivity troponin I level, coronary angiography was
performed. Significant proximal stenosis in the left anterior descending
artery was found. Percutaneous coronary intervention with a drug-eluting
stent was performed in the context of cardiogenic shock. The patient
improved progressively with the aid of levosimendan. Vasopressors and
temporary pacemaker were successfully removed, and the patient was
extubated 8 days later.</div><div>Cardiac magnetic resonance (CMR) showed reduced left ventricular
ejection fraction (LVEF 27%) and sub-epicardial late gadolinium
enhancement in the inferior septum and anterior wall (Figure 1 panel E
and F), compatible with subacute myocarditis (videos 2 and 3). Latter
findings made ischemic or Takotsubo cardiomyopathy unlikely. A few days
later, he had hypotension and new onset complete AV block with right
bundle branch block and ST-segment depression in V1-V3 (Figure 1 panel
B). Coronary angiography was performed to ensure stent patency and
definitive pacemaker was placed. He was started in guideline directed
medical treatment for heart failure. Endomyocardial biopsy was not
performed due to clinical improvement and increased s risk to health
care providers. A few days later, he was discharged. On follow up one
month later left ventricular function recovered.</div><div>Myocarditis is a well-described feature of other viral illnesses;
however, in patients with SARS-CoV-2, data is limited to a few case
reports. Although myocardial injury is common in patients with severe
disease. Histopathological studies have only shown a few interstitial
mononuclear inflammatory infiltrates in the myocardium (3). Cardiac
magnetic resonance is a valuable tool for myocardial tissue
characterization in vivo validated against histology in a wide range of
clinical scenarios. Interestingly in patients with moderate to severe
SARS-CoV-2 disease, CMR can detect late gadolinium enhancement (LGE) in
half of recovered patients who reported chest pain or palpitations (4).
Thus, myocarditis might be more common than expected.</div><div>Complete AV block in patients with SARS-CoV-2 myocarditis might occur.
The mechanism involved is yet to be defined. The high expression of
Angiotensin-converting enzyme 2 in heart and vessels might pose these
tissues as primary target of the disease. A better understanding of
cardiac complications of SARS-Cov2 infection is needed to guide
clinicians in the treatment of these patients.</div><div>Author contributions</div><div>Rodríguez-Zanella Hugo MD , Care of the patient, Conceptualization,
Writing original draft, Writing- review and editing, Approval</div><div>Gutiérrez-Villaseñor Alan O.MD, Care of the patient, Data Curation,
review and editing, Approval</div><div>Romero-González Juan P. MD, Care of the patient, Data Curation, review
and editing, Approval</div><div>Adriana Torres-Machorro MD Care of the patient, Data Curation, review
and editing, Approval</div><div>Ana Karla Tobias Morales MD, Care of the patient, Data Curation,
Writing- review and editing, Approval</div><div>Silvio A, Ñamendys Silva MD, MSc, FCCP,FCCM Care of the patient,
Conceptualization, Writing- review and editing,</div><div>References.</div><ol><li>Shi S Shi S, Qin M, Shen B, et al. Association of cardiac injury with
mortality in hospitalized patients with COVID-19 in Wuhan, China. JAMA
Cardiol 2020 March 25 (Epub ahead of print)</li><li>Guo T, Fan Y, Chen M, Wu X, Zhang L, He T, Wang H, Wan J, Wang X, Lu
Z. Cardiovascular implications of fatal outcomes of patients with
coronavirus disease 2019 (COVID-19). JAMA Cardiol 2020 March 27 (Epub
ahead of print).</li><li>Xu Z, Shi L, Wang Y, et al. Pathological findings of COVID-19
associated with acute respiratory distress syndrome. Lancet Respir Med
2020 Apr;8(4):420-422.</li><li>Huang L, Zhao P, Dazhong T, et al. Cardiac involvement in recovered
COVID-19 patients identified by magnetic resonance imaging. J Am Coll
Cardiol Img. 2020 May 11. (Epub ahead of print)</li></ol><div>Figure 1. Representative images during the patient hospital stay. Panel
A. 12 lead surface ECG with complete AV block and left bundle branch
block at day 12 from admission. Panel B. 12 lead ECG with complete AV
block and right bundle branch block. Panel C. CT showing bilateral
interstitial infiltrates typical of Covid 19 pneumonia (arrow). Panel D.
Four chamber echocardiographic view showing apical dyskinesia (arrow).
Panel E. Cardiac magnetic resonance cine image, short axis view with
normal wall thickness. Panel F. Late gadolinium enhancement CMR showing
subepicardial enhancement in the inferior septum. LA= left atrium, LV=
left ventricle, RA= right atrium, RV right ventricle.</div><div>Video 1. Apical four chamber view, showing apical dyskinesia, and
normal wall motion of the basal segments. LA= left atrium, LV= left
ventricle,</div><div>RA= right atrium, RV right ventricle.
Video 2.  CMR
short axis view comparative.
A.  Cine, (SSFP) showing reduced left ventricular function
B. T1 weighted sequence showing normal pericardium.
C.  Short time recovery image, showing no edema.
D. Late gadolinium enhancement imaging, showing epicardial anterior
and intramyocardial inferoseptal enhancement</div><div>LV= left ventricle, RV right ventricle.
Video 3. CMR
cine images in two, three and four chamber view showing
reduced left ventricular function, and wall motion abnormalities in
the apical segments. LA= left atrium, LV= left ventricle, LVOT= left
ventricular outflow tract, RA= right atrium, RV right ventricle.</div>