COVID-19 as a potential trigger for refractory arrhythmias and electrical storm in a patient with dilated cardiomyopathy: a case report

Arrhythmias occur both in the acute coronavirus disease 2019 (COVID-19) and in the post-acute period, which may be associated with the long-term SARS-CoV-2 persistence. In a case report, patient with primary dilated cardiomyopathy, an implanted cardioverter-defibrillator, recurrent ventricular arrhythmias, and an electrical storm are presented. The patient was repeatedly hospitalized in a city hospital, where electrical cardioversion, antiarrhythmic therapy, radiofrequency ablation of recurrent ventricular tachycardia regions, including emergency ("lifesaving") combined catheter radiofrequency destruction of the electrical storm substrate, was performed. Subsequently, against the background of ongoing postoperative therapy, massive pulmonary embolism (PE) suddenly developed, which led to the death. Autopsy established that the cause of the patient’s death was massive pulmonary embolism; SARS-CoV-2 and enterovirus was detected in the myocardium. Based on an autopsy study, the patient was diagnosed with primary dilated cardiomyopathy with secondary active chronic lymphocytic myocarditis.

1. Dherange P, Lang J, Qian P, et al. Arrhythmias and COVID-19: A Review. JACC Clin Electrophysiol. 2020;6(9):1193-204. doi:10.1016/j.jacep.2020.08.002.

2. Peter RS, Nieters A, Kräusslich HG, et al. Post-acute sequelae of covid-19 six to 12 months after infection: population based study. BMJ. 2022;379:e071050. doi:10.1136/bmj-2022-071050.

3. Nalbandian A, Sehgal K, Gupta A, et al. Post-acute COVID-19 syndrome. Nat Med. 2021;27(4):601-15. doi:10.1038/s41591-021-01283-z.

4. Sherif ZA, Gomez CR, Connors TJ, et al. Pathogenic mechanisms of post-acute sequelae of SARS-CoV-2 infection (PASC). Elife. 2023;12:e86002. doi:10.7554/eLife.86002.

5. Mirò Ò, Sabaté M, Jiménez S, et al. A case-control, multicentre study of consecutive patients with COVID-19 and acute (myo)pericarditis: incidence, risk factors, clinical characteristics and outcomes. Emerg Med J. 2022;39(5):402-10. doi:10.1136/emermed-2020-210977.

6. Long B, Brady WJ, Koyfman A, et al. Cardiovascular complications in COVID-19. Am J Emerg Med. 2020;38(7):1504-7. doi:10.1016/j.ajem.2020.04.048.

7. Mitrofanova LB, Makarov IA, Runov AL, et al. Clinical-morphological and molecularbiological study of the myocardium in patients with COVID-19. Russian Journal of Cardiology. 2022;27(7):4810. (In Russ.) doi:10.15829/1560-4071-2022-4810.

8. Mitrofanova LB, Makarov IA, Gorshkov AN, et al. Comparative Study of the Myocardium of Patients from Four COVID-19 Waves. Diagnostics (Basel). 2023;13(9):1645. doi:10.3390/diagnostics13091645.

9. Xu SC, Wu W, Zhang SY. Manifestations and Mechanism of SARS-CoV2 Mediated Cardiac Injury. Int J Biol Sci. 2022;18(7):2703-13. doi:10.7150/ijbs.69677.

10. Osadchy AM, Semenyuta VV, Kamenev AV, et al. Features of the electroanatomical substrate of atrial fibrillation in patients after SARS-CoV-2 infection. Russian Journal of Cardiology. 2021;26(7):4526. (In Russ.) doi:10.15829/1560-4071-2021-4526.

11. Robinson FA, Mihealsick RP, Wagener BM, et al. Role of angiotensin-converting enzyme 2 and pericytes in cardiac complications of COVID-19 infection. Am J Physiol Heart Circ Physiol. 2020;319(5):H1059-H1068. doi:10.1152/ajpheart.00681.2020.

12. Fox SE, Falgout L, Vander Heide RS. COVID-19 myocarditis: quantitative analysis of the inflammatory infiltrate and a proposed mechanism. Cardiovasc Pathol. 2021;54:107361. doi:10.1016/j.carpath.2021.107361.

13. Andréoletti L, Bourlet T, Moukassa D, et al. Enteroviruses can persist with or without active viral replication in cardiac tissue of patients with end-stage ischemic or dilated cardiomyopathy. J Infect Dis. 2000;182(4):1222-7. doi:10.1086/315818.

14. Makarov I, Mayrina S, Makarova T, et al. Morphological Changes in the Myocardium of Patients with Post-Acute Coronavirus Syndrome: A Study of Endomyocardial Biopsies. Diagnostics. 2023;13(13):2212. doi:10.3390/diagnostics13132212.

15. Arutyunov GP, Paleev FN, Moiseeva OM, et al. Myocarditis in adults. Clinical guidelines 2020. Russian Journal of Cardiology. 2021;26(11):4790. (In Russ.) doi:10.15829/1560-4071-2021-4790.