Case Presentation:
A 68-year-old Caucasian woman presented to our emergency department at the end of February 2020, referring persistent fever unresponsive to oral antibiotic and antipyretic therapy for the past 6 days, associated with cough, shortness of breath and transient dizziness episodes.
Patient’s medical history revealed a prior inferolateral ST elevation myocardial infarction (MI) in 2014. For the persistence of severe left ventricular dysfunction, she was implanted three months later with a single-chamber implantable cardioverter defibrillator (ICD) in primary prevention of sudden cardiac death.
Subsequent follow-up was uneventful, and she never experienced any device intervention.
At the time of hospital admission, most laboratory tests were within normal range, except for increased high-sensitivity C-reactive protein (C-PR) values (27.6 mg/L). Arterial blood gas analysis revealed oxygen saturation of 94% and oxygen partial pressure of 67 mm Hg. Two polymerase chain reaction assays of the oropharyngeal swab sample were negative for the SARS-CoV-2 nucleic acid. Chest radiograph showed a pulmonary consolidation area in left inferior lung lobe, suggestive for pneumonia (Figure 1, A-B).
Non-invasive ventilation and intravenous empirical antibiotic therapy were attempted with clinical improvement within few days.
During the eighth day of hospital stay, the patient had multiple episodes of sustained ventricular tachycardia (VT)/ventricular fibrillation (VF) treated with ICD shocks (Figure 1, C). At device interrogation, frequent mild-symptomatic ventricular arrhythmia episodes were detected during the past 20 days, self-terminating or successfully interrupted with antitachycardia pacing (ATP). Electrical storm (12 episodes over 24 h) persisted despite intravenous infusion of beta blockers, amiodarone and deep sedation.
Repeated blood test showed C-RP reduction (16.8 mg/dL) while high-sensitivity troponin T level remained negative (< 15 ng/L). Chest radiograph control showed a progressive resolution of pneumonia findings.
Transthoracic echocardiogram confirmed the previous findings of dyskinesia of the inferior wall and aneurysm of the mid and apical parts, with reduced left ventricular ejection fraction of 37%.
Catheter ablation was performed the day after, with the patient afebrile in the previous 72 hours.
Left ventricle was first mapped using transseptal approach with a Pentaray catheter and electroanatomic CARTO3 mapping system (Biosense Webster, Inc., CA, USA). Voltage map showed a large post-MI scar zone in inferolateral LV wall with local abnormal ventricular activity signals (Figure 2).
Scar homogenization was performed with a 3.5 mm tip magnetic irrigated radiofrequency catheter (Navistar® RMT Thermocool, Biosense Webster) with a maximum power of 55 W in concert with a remote magnetic navigation system (NiobeTM, Stereotaxis, Inc., St. Louis, MO, USA).
At the end of ablation procedure, non-inducibility of clinical VT by programmed ventricular stimulation was confirmed.
During the following hospital stay, continuous ECG monitoring did not show further VT events and the patient remained apyretic, with resolution of pneumonia. Despite clinical improvement, nasopharyngeal swab was repeated before home discharge with a positive result for SARS-CoV-2 and this case was finally diagnosed with Covid-19 pneumonia.