key: cord-0837176-u3wuzufr authors: Zanchi, Simone; La Greca, Carmelo; Di Nanni, Nunzia; Fogliata, Emma; Zani, Mariangela; Pecora, Domenico title: A reproducible sensor pattern to suspect COVID19 pulmonary infection with LATITUDE. Case report and literature review date: 2022-02-23 journal: Pacing Clin Electrophysiol DOI: 10.1111/pace.14469 sha: 7b71de4e20172f239d5bd05438ace035ab4ad1c5 doc_id: 837176 cord_uid: u3wuzufr A 78 year‐old patient with postischaemic dilated cardiomyopathy and severely reduced ejection fraction was implanted with a Boston Scientific RESONATE X4 CRT‐D and followed by LATITUDE remote monitoring platform. From the end of January to the end of March 2021 he was hospitalized for COVID19 pneumonia followed by two episodes of acute heart decompensation with bilateral pleural effusion. We remotely followed the patient and identified a typical Heart Logic sensor pattern linked to the COVID19 pneumonia, different from the one linked to the heart failure (HF). We eventually made a literature review on the topic. Severe acute respiratory syndrome Coronavirus 2 (SARS-CoV-2) has emerged from December 2019 as a new human viral pathogen, which targets the respiratory tract and is responsible of the ongoing global pandemic. Infection with SARS-CoV-2 has a broad range of symptoms: from asymptomatic or mildly symptomatic infection to a bilateral pneumonia with severe respiratory failure, 1,2 that can lead to an acute respiratory distress syndrome. Chronically ill patients, as heart failure (HF) patients, are more likely to develop severe symptoms and a poorer outcome than patients without any comorbidities. 3 As a consequence, remote home monitoring during this period has been critical for patients, in order to avoid unnecessary exposure within the health care system. Many patients with chronic HF have implantable cardiac devices, which can be equipped with physiologic sensors that can be remotely monitored. A 78-year-old male with post-ischaemic dilated cardiomyopathy, 28% left ventricular ejection fraction, left bundle branch block and repeated episodes of HF was implanted with a Boston Scientific RESONATE X4 CRT-D in 2017 and since then he has been followed by LATITUDE remote monitoring system at our center. He also had paroxysmal atrial tachycardias, type II diabetes mellitus, chronic kidney disease, dyslipidemia and arterial hypertension. He started to experience exertional dyspnea and orthopnea without fever and on January 21st, 2021 he was referred to the emergency room of a different center in our city. A chest computed tomography (CT) scan revealed bilateral interstitial alveolar consolidation surrounded by ground glass areas suggestive of COVID19 pneumonia, associated with bilateral pleural effusion. The blood tests showed a mild neutrophilic leukocytosis with a moderate increase of both C-Reactive Protein (CRP) and B-natriuretic peptide (BNP); he was tested positive for SARS-CoV-2 on 23rd January. The patient was treated with parenteral broad-spectrum antimicrobial therapy and diuretic therapy and was then discharged on 27th January with the diagnosis of interstitial COVID19 pneumonia with secondary acute HF. Thereafter on 8th February the patient was re-hospitalised for acute HF. The SARS-CoV-2 nasopharyngeal swab was still positive and the repeated chest CT scan revealed the persistence of bilateral ground glass areas with parenchymal consolidations and moderate pleural effusion. He was treated with oxygen, diuretic and antimicrobial combined with steroidal therapy and discharged on 24th February. The HL algorithm sent an alert to our center at the end of January. The patient was never admitted to our center, but he was contacted by phone when HL exceeded the alert threshold and then remotely followed. The tracings were then reviewed and associated with the clinical context. As displayed in Figure 1 , from the symptoms' onset until the beginning of February an increase in first heart sound amplitude (S1), intrathoracic impedance (ITI), respiratory rate (RR) and nocturnal heart rate (nHR) were identified. Then, S1 and ITI showed a mutual decrease, while RR and nHR had a biphasic pattern. No significant variations were seen in activity level. The Heart Logic (HL) is a multisensor HF index and alert algorithm that can predict impending HF decompensation, 4 by combining data derived from multiple sensors: S1 and third heart sound amplitude (S3), Not hospitalized data show that sensitivity and accuracy in predicting HF episodes with ITI-based algorithms are variable and that they are not often clinically useful, 6, 7 suggesting that ITI alone may not be enough for this purpose. In our case, as represented in Figure 1 , the symptom onset coincided with a mounting increase of HL index, which exceeded the threshold of 16 by the end of January, remained elevated reaching a maximum value of more than 50 at the beginning of March and finally normalized by the end of March. In the previous episodes of HF, all not requiring hospitalization, the HL index of our patient had never reached a value of more than 30. Regarding the HL sensors trend, we can distinguish a biphasic pattern, the first connected to the COVID-19 pneumonia and the other one to the subsequent HF episodes. From the end of January until the middle of February the S1 heart sound, the RR and the nHR were increased, while S3 and activity level didn't show any changes, interestingly the ITI showed an increasing trend. This pattern is in line with the typical COVID-19 HL pattern we found in our literature review. From the middle of February a second pattern emerged reflecting the HF episodes triggered by the pulmonary infection: the ITI fell down to less than 18 Ohm because of bilateral pleural effusion and simultaneously the S1 decreased until 1.1 mG, while RR and nHR remained high and S3 and activity level did not show any changes. It is important to underline the extremely high value of HL index during the HF episodes reflecting the severity of patient's clinical condition. In this particular case, the oral therapy adjustment alone, driven by the home monitoring, was not enough to prevent further HF hospitalizations. From our review of the literature, we found two case reports 8,9 and 2 case series 10, 11 reporting the HL physiologic sensor changes, for a total of eight patients with SARS-CoV-2 infection. As represented in Table 1 , the patients were all infected by SARS-CoV-2 and even though only 3/8 patients had a more severe clinical manifestation with pneumonia, in 8/8 patients (100%) an increase in the ITI in association with an increase in the RR and a decrease in the activity level was present. This pattern seems to be related to SARS-CoV-2 infection, as it differs from what happens during impending HF, where a rapid shallow breathing pattern associated with a decrease of the activity level is common, 4 in association with a decrease in ITI, because of fluid overload due to HF. 12 Lung hyperinflation with air trapping 9 can be the reason of the increased ITI in SARS-CoV-2 infection. Heart sounds are also clinical relevant parameters that can vary during HF: S1 is associated with ventricular contraction status 4 and is supposed to decrease during heart acute decompensation; on the other hand S3 reflects the early diastolic filling, and is a pathophysiological landmark of acute HF. In COVID-19 patients heart sounds seem not to have a common pattern, as S1 was increased in 3/8 cases while in 4/8 patients it was not significantly modified and S3 was decreased in 5/8 cases while in 2/8 it was increased. The nHR, considered as an indicator of cardiac status, was increased in 4/8 (50%) cases. Taking together all the sensor information, the HL set an alert in 6/8 patients. Eventually, Gardner et al. 13 patients to non-COVID-19 pneumonia patients, suggesting an underlying pathophysiological mechanism related to pulmonary infection. The earliest sensor change was the RR, followed by temperature. 13 Furthermore, no significant changes in S1 and S3 amplitude were detected when comparing HF patients to COVID-19 and non-COVID-19 pneumonia patients. 13 The present case and the literature review show that LATITUDE remote monitoring algorithm may become a useful tool to remotely detect SARS-CoV-2 infection, distinguish it from HF and lead to an early hospitalization for symptomatic patients or to a simple home monitoring. HL algorithm may be a useful tool to detect non-HF-related decompensation, such as SARS-CoV-2 infection. The most common HL pattern for SARS-CoV-2 infection seems to be an increase in ITI combined with an increase in the RR. Simone Zanchi MD and Carmelo La Greca MD drafted the manuscript; all other authors contributed to the critical review of the manuscript. Baseline characteristics and outcomes of 1591 patients infected with SARS-CoV-2 admitted to ICUs of the Lombardy Region Presenting characteristics, comorbidities, and outcomes among 5700 patients hospitalized with COVID-19 in the New York City Area Impact of the presence of heart disease, cardiovascular medications and cardiac events on outcome in COVID-19 A multisensor algorithm predicts heart failure events in patients with implanted devices Changes in intrathoracic impedance are associated with subsequent risk of hospitalizations for acute decompensated heart failure: clinical Utility of implanted device monitoring without a patient alert CorVue algorithm efficacy to predict heart failure in real life: unnecessary and potentially misleading information? An improved algorithm calculated from intrathoracic impedance can precisely diagnose preclinical heart failure events: sub-analysis of a multicenter MOMO-TARO (Monitoring and Management of OptiVol Alert to Reduce Heart Failure Hospitalization) trial study Use of a novel implantable cardioverter-defibrillator multisensor algorithm for heart failure monitoring in a COVID-19 patient: a case report A steep increase in the heart logic index predicts COVID-19 disease in an advanced heart failure patient Novel findings of respiratory rate increases using the multisensor HeartLogic heart failure monitoring algorithm in COVID-19-positive patients: a case series Case reports of implantable cardiac device physiologic sensor changes in subjects with coronavirus disease-2019 infection Clinical utility of intrathoracic impedance monitoring to alert patients with an implanted device of deteriorating chronic heart failure Multiparameter diagnostic sensor measurements in heart failure patients presenting with SARS-CoV-2 infection. ESC Heart Fail. 2021:ehf2.13500 The authors report no conflict of interest regarding this topic. Simone Zanchi MD https://orcid.org/0000-0003-1379-6557Carmelo La Greca MD https://orcid.org/0000-0003-2692-7333