Many theories have been proposed to understand the connection between heart conduction disease and COVID-19 vaccines. Common pathways thought to contribute to clinical arrhythmogenesis include hypoxia, electrolyte imbalance, myocardial injury, and cytokine or inflammatory storms (7). Congenital complete heart blocks (CCHB) are believed to originate from the inflammatory and fibrotic processes in fetal conduction tissues due to the deposition of maternal antibody immune complexes (anti-Ro and anti-La). Likewise, there is a possibility that the inactivated vaccine has a similar pathophysiological nature as CCHB in causing the AV block. However, this rationale is thought to cause transient AV blocks, which contradicts the non-transient nature of the AV block in the case we present (6).
In terms of the cytokine-mediated immune response, a previous article explored its connection to COVID-19 vaccine-induced myocarditis, representing a potential acquired cause of CCD characterized by inflammation and potential necrosis of the myocytes (8, 9). The article suggests that this reactogenicity is present in messenger RNA (mRNA) vaccines only, which could potentially explain our patient’s case. Conversely, some evidence suggests an association between non-mRNA vaccines, such as vector-based ones, and myocarditis. However, the mechanism behind these links lack a foundational understanding (10).
Recent literature aligns with our findings, reporting cardiac abnormalities following COVID-19 vaccination. In one case series, two elderly and one adult patients with no prior history of known underlying coronary pathologies presented with cardiovascular symptoms, coupled with biochemical and electrocardiographic findings of myocardial injury after receiving their first Pfizer-BioNTech COVID-19 shots (11). Another article reports similar findings in an elderly Caucasian patient after receiving his first Pfizer-BioNTech COVID-19 vaccine shot (3). Furthermore, cardiovascular complications are also possible, where one article reports similar findings in an elderly patient who, after receiving the COVID-19 BBIBP-CorV (Sino-pharm) vaccine, was also treated with permanent pacemaker implantation. This finding must be further investigated by comparing the nature and outcomes of different vaccines (6). Finally, to the best of our knowledge, no other articles report findings that revolve around conductive cardiac diseases manifesting after COVID-19 vaccine shots.
The protocols for managing device implantation during COVID-19 infection remain unclear. Interestingly, two papers detail cases of patients with complete heart blocks following COVID-19 infections, who underwent pacemaker implantations (12, 13). Additionally, one paper details the case of BNT-162b2 mRNA vaccine-induced myocarditis (14). However, we are the first to report conductive cardiac abnormalities following COVID-19 vaccination in a young Middle Eastern female patient with no underlying cardiac pathologies. Notably, the patient’s family members who have also taken the same vaccine experienced minimal and well-tolerated side effects. In contrast, these rare adverse effects were previously reported exclusively in elderly patients with underlying cardiac pathologies (3, 6, 11). Lastly, non-conductive side effects may manifest following COVID-19 infections, such as acute arterial thrombosis events following COVID-19 infections, highlighting the importance of widespread awareness of potential complications in healthcare settings (15).
Our case report undeniably presents unique and novel findings as the 16-year-old female patient developed a third-degree atrioventricular block after receiving the Pfizer-BioNTech COVID-19 vaccine, necessitating pacemaker implantation for resolution; our report highlights the imperative for clinicians and healthcare professionals to be aware of potential cardiac manifestations post-COVID-19 vaccinations, facilitating improved preparedness for complications in healthcare settings, and the implications of these findings may inspire further scientific exploration into the molecular and pharmacological underpinnings of such occurrences in young patients, contributing to the limited literature and enhancing our understanding of the conductive cardiac system and COVID-19 vaccines.