key: cord-0737345-2jynw73i
authors: Bertini, Matteo; Vitali, Francesco; Malagù, Michele; Rapezzi, Claudio
title: Atrial Flutter in Patient With Critical COVID-19: Beneficial Effects of Rhythm Control on Respiratory Distress
date: 2021-01-06
journal: JACC Case Rep
DOI: 10.1016/j.jaccas.2020.11.015
sha: 88fa172f70da60b7082e306c0d62dfa2043c86cd
doc_id: 737345
cord_uid: 2jynw73i

We report the case of a patient critically ill with coronavirus disease–2019 (COVID-19) in which atrial flutter with high ventricular response rate occurred, contributing to worsening of the respiratory distress. After failure of noninvasive rate and rhythm control strategies, successful transcatheter ablation was performed and the respiratory distress of the patient improved. (Level of Difficulty: Beginner.)

C oronavirus disease-2019 (COVID-19) has important implications for the cardiovascular system, including the onset of arrhythmias (1) . Furthermore, arrhythmias may contribute to deteriorating respiratory distress, establishing a vicious circle.

We report the case of a 61-year-old man admitted to the hospital with dyspnea, cough, and fever (39 C).

Blood pressure was 120/60 mm Hg and oxygen saturation level was 89% with respiratory rate of 33 breaths per minute. The acute deterioration of respiratory distress needed invasive ventilation and the patient was promptly intubated. High-resolution computed tomography showed bilateral severe interstitial pneumonia with "crazy paving" aspects ( Figure 1A ). At admission, the electrocardiogram showed sinus tachycardia of 100 beats/min. The nasopharyngeal swab detected severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) viral RNA. After 9 days the patient improved and was downgraded to noninvasive ventilation with helmet. The following day, the respiratory distress worsened and atrial flutter with high ventricular response rate occurred ( Figure 1B) . The echocardiogram showed left ventricular ejection fraction of 50%, mild right atrial dilatation, and signs of increased left ventricular filling pressures (mean averaged E/e 0 was 16). An external electrical cardioversion initially restored sinus rhythm but atrial flutter relapsed early. A second cardioversion was attempted with intravenous amiodarone; sinus rhythm lasted only few hours and then atrial flutter started again. Due to the failure of rhythm, rate control strategy with prolonged intravenous full dose of metoprolol, verapamil, and digoxin was attempted but was equally ineffective. The persistent ventricular rate of 150 beats/ min contributed to deterioration of the respiratory status, raising the issue of reverting to invasive mechanical ventilation. Therefore, after extensive multidisciplinary team discussion, we decided to perform transcatheter ablation of atrial flutter to achieve rhythm control. In addition to the difficulties of invasive procedure for a patient with COVID-19, we were well aware of two other problems: 1) the patient with helmet is normally seated but has to remain supine during the whole procedure, which, therefore, needs to be as fast as possible; and 2) the use of fluoroscopy is challenging by the presence of the helmet. Our option was for a zero fluoroscopy procedure, using a three-dimensional electroanatomic mapping system (EnSite Precision, Abbott, St. Paul, Minnesota) (2). Recommendations from international consensus were followed to ensure patient safety and minimize healthcare professional exposure (3). The only people allowed in the operative room with full protection, including FFP3 face mask, surgical gown, double gloves, and face shield, were a senior electrophysiologist, 2 anesthesiologists, and a specialized nurse. Double right femoral venous access was used, and the patient was maintained supine, ventilated with noninvasive helmet ( Figure 1D) . Endocardial mapping confirmed a cavo-tricuspid isthmus-dependent atrial flutter that was treated with radiofrequency ablation, restoring sinus rhythm. Bidirectional conduction block across the cavo-tricuspid isthmus was confirmed using activation map pacing from the coronary sinus ostium ( Figure 1D ) and from the lateral wall of right atrium. Procedural time including preparation of the patient was < 1 h. With the restoration of sinus rhythm ( Figure 1E) , the respiratory status improved, the oxygen saturation rapidly increased from 84% to 98%, and the patient was feeling better. This case highlights the contribution of atrial flutter with high ventricular response rate to respiratory deterioration in patients with COVID-19 and the beneficial role of rhythm control achieved with transcatheter ablation (with ad hoc precautions). The efficacy of medical therapy for rate or rhythm control of atrial flutter in critically ill patients is generally low for several reasons, including the trigger constituted by the underlying disease, the organism response, or the concomitant treatments. Furthermore, using amiodarone for rhythm control has potentially severe adverse effects of pulmonary toxicity (direct cytotoxicity and hypersensitivity reaction) and

it should be used with caution in patients with respiratory distress. Transcatheter ablation is relatively simple and the most effective treatment to maintain sinus rhythm in atrial flutter, but, thus far, there are no specific data in the setting of COVID-19.

The authors have reported that they have no relationships relevant to the contents of this paper to disclose. 

The science underlying COVID-19: implications for the cardiovascular system

Near zerO fluoroscopic exPosure during catheter ablAtion of supRavenTricular arrhYthmias: the NO-PARTY multicentre randomized trial

Atrial Flutter in Patient With COVID-19 J A N U A R Y 2 0 2 1 : 1 6 2 -4