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.