Ventricular Tachycardia With Epicardial and Pericardial Fibrosis 6 Months After Resolution of Subclinical COVID-19

A Case Report

Jonathan Solaimanzadeh; Aaron Freilich; Michael R Sood

Disclosures

J Med Case Reports. 2021;15(305) 

In This Article

Discussion

Emerging evidence has shown myocardial involvement in patients with covid-19. In one prospective, observational cohort study, 100 patients who had COVID-19 underwent CMR which revealed cardiac involvement in 78 percent of patients with the average follow-up time of 71 days. More than half of the patients had ongoing myocardial inflammation, which was independent of preexisting conditions and their severity of illness[18]

In another study, 26 competitive athletes who were diagnosed with the COVID-19 infection, all of which were either asymptomatic or presented with mild symptoms (sore throat, shortness of breath, myalgias, fever underwent CMR. Only four subjects (15%) had CMR findings suggestive of myocarditis. Pericardial effusion was present in only 2 patients.[19] Lui Haung, et al., demonstrated 58% of patients had abnormal CMR findings, 54% with myocardial edema and LGE in 31% of patients in a retrospective study with an average patient age of 38-years-of age and follow-up time from illness to scan of 47 days.[20] Despite emerging data, much remains uncertain about the true prevalence as well as the long-term cardiac effects in covid-19. Many of the patients studied have had their CMR performed within a short window of their covid-19 illness and usually due to evident overlapping cardiac symptoms. Our case shows one of the longer CMR scans done from time of illness documenting covid-19 involvement to date.

Our patient appears to have developed symptoms of palpitations and dyspnea 3 months after his clinical resolution of covid-19, which is markedly unusual in the timing of his presenting cardiac symptoms. It is unclear if he had underlying inflammation or subclinical myocarditis, however, his echocardiogram and ECG were both notably normal, even on month 4 after illness. He also had high covid-19 antibody titers at that time, which suggested immunity. Furthermore, his CMR (6 months after illness) showed LGE with the absence of T2 weighted myocardial edema, which may reflect less of an acute myocardial injury response and more so a chronic process of fibrosis or scar remodelling.[21–24] It is also unclear if his trivial pericardial effusion seen on CMR at the time of scan was representing a resolving effusion or a dynamic intra-cardiac process (his echocardiogram done 2 months earlier had no effusion). Similarly, his new ECG abnormalities noted on month 7 after illness also correlate in an unusually similar time presentation, as illustrated (Image 1–2).

Our patient may have also had insidious or subclinical cardiac involvement that may have been exacerbated by returning to heavy aerobic exercise once he felt recovered. This may explain the large time gap between his recovery of covid-19 and the development of cardiac symptoms and findings. There is emerging evidence that myocarditis in covid-19 can be detected in athletes via CMR despite a normal ECG, echocardiogram and/or other laboratory or imaging parameters.[25] This may also support a low threshold to pursue advanced imaging modalities such as CMR, if clinically indicated. Lastly, our patient did not have screening cardiac biomarkers, which have been shown as a good utility in a large systemic review by Shafi et al. for cardiac involvement during active covid-19 infection.[26] This was due to his self-limited illness and the need for quarantine, for which he did not seek or warrant medical care and may represent many recovered patients.

Follow-up

The patient is to undergo further ambulatory telemetry monitoring. Pharmacotherapy with beta blockade has been initiated with improvement in his palpitations. Electrophysiological testing with electrical mapping may be considered on his course if persistent ventricular tachycardia is detected or based on the development of other high-risk clinical features, and it may help to correlate electrical or ectopic origins with LGE patterns. Cardiac ablation and/or an implantable defibrillator may also be indicated in the future depending on his clinical course, although not warranted at this time. Finally, a follow-up CMR may also be considered to reassess fibrosis patterns or further myocardial involvement.

processing....