Outcome and implications:
As the patient lost follow-up after 4 weeks, we do not have any data
about the long-term outcome of our patient. New-onset AV node disease
can develop from ischemic cardiac disease, cardiomyopathy, myocarditis,
endocarditis, thyroid disease, and medications. [1,4] COVID-19 may
contribute to the etiology of AV node conduction disruption. COVID-19
has been shown to contribute to and cause cardiovascular diseases in
19.7% of patients. [2] A study performed in June of 2020, analyzed
the occurrence of varying cardiac arrhythmias in COVID-19 patients
reported by 1,197 respondents. These issues ranged from atrial
fibrillation (20.79% reported) and atrial flutter (5.42%) to AV block
(13.57%), and bundle branch blocks (2.42%). [11] Emerging case
reports have shown that patients with COVID-19 have occasionally
developed heart block. One case presented a 44-year-old male with
new-onset diabetes and no cardiac history who tested positive
for COVID-19 and experienced transient complete heart block. [1]
Another case presented an 82-year-old male who presented with shortness
of breath and a dry cough. He tested positive for COVID-19 and shortly
after endotracheal intubation developed a complete heart block. This
report also presented a 55-year-old male with no medical history who
developed transient second-degree heart block on day six of admission
after receiving a positive COVID-19, and a 43-year-old male with no
medical history who tested positive for COVID-19 on day six of admission
and developed intermittent complete heart block on day 24 of admission.
[3] Additionally, a case was presented of a 10-year-old male with a
7-day history of fever, fatigue, cough, and diarrhea who developed
first-degree heart block after 24 hours of admission that resolved
overnight, and transient complete heart block on day three of admission.
[10] None of these cases resulted in permanent heart block however
they do demonstrate that transient conduction abnormalities may be seen
in the setting of COVID-19.
While all degrees of AV block have been reported in COVID-19 patients,
there have been few to no reports on patients developing permanent AV
block from COVID-19 infections. In this case, we present a 36-year-old
male with no previous significant medical history who developed
permanent third-degree AV heart block. While the long-term effects of
COVID-19 continue to be studied this case presents a previously
unreported permanent complication of COVID-19. The patient had the
vaccination before few months before his breakthrough infection.
Therefore, it is doubtful that the vaccine played any role in the
occurrence of his third-degree AV block. We cannot be 100% certain that
his third-degree AV block was related to COVID-19 infection. However,
the occurrence of these arrhythmias shorty after having COVID-19
infection with symptoms is highly suggestive of COVID-19 induced
third-degree AV block. His MRI was negative for any scaring. However,
with a spatial resolution of a cardiac MRI of 1.5 x 1.8 mm, [12]
would be impossible to detect a small area of scarring in the AV
node. Case series of 6 patients requiring permanent pacemaker insertion
during their COVID-19 infection have been reported. [13] However,
all these 6 patients were elderly patients with severe COVID-19
infection requiring hospitalization for very critical conditions. Our
case is unique as the third-degree AV block occurred in a young person
with previous vaccination who had only self-limiting mild upper
respiratory symptoms.
Outcomes and
Implications: Permanent 3rd degree AV block in the setting of COVID-19
infection can occur in young patients. However, the long-term outcome is
not known. The rule of pacemaker insertion in young asymptomatic
patients remains unknown.
Conclusion: Clinicians need to be aware of the occurrence of
permanent high-grade AV block even in young patients with COVID-19
infection regardless of immunization status. This condition can
occur in patients with normal cardiac function and normal MRI. Future
studies hopefully can shed light on the pathogenesis of this condition.