Temporary third-degree atrioventricular block in a case of apical ballooning syndrome

Permanent Pacemaker Implantation in a Patient with Takotsubo Cardiomyopathy and Complete Atrioventricular Block

This case report presents a patient with Takotsubo cardiomyopathy (TCM) and complete atrioventricular (AV) block who was treated with permanent pacemaker implantation. A 78-year-old woman with a history of hypertension presented with a 6-month history of palpitations. On initial evaluation, her heart rate was 40 beats/minute. Electrocardiography revealed a complete AV block and T-wave inversion in these leads: I, II, aVL, aVF, and V3–6. Echocardiography showed akinesis from the midventricle to the apex and hyperkinesis on the basal segments. The patient was diagnosed with TCM and complete AV block. Because improvement of TCM may subsequently improve the AV node dysfunction associated with TCM, the patient was admitted for treatment of heart failure without pacemaker implantation. The left ventricular (LV) abnormal wall motion improved gradually; however, the AV block persisted intermittently. On hospital day 14, a pause of 5–6 seconds without LV contraction was observed, and permanent pacemaker implantation was performed. On day 92, echocardiography revealed normal LV wall motion. However, electrocardiography revealed that the pacemaker rhythm with atrial sensing and ventricular pacing remained. Although specific degree of damage that may result from AV block associated with TCM is unknown, some of these patients require pacemaker implantation, despite improvement of abnormality in LV wall motion.

High-degree atrioventricular block. An unusual presentation of Takotsubo cardiomyopathy: a case report

Background

Takotsubo cardiomyopathy is a non-ischemic cardiomyopathy characterized by acute left ventricular systolic dysfunction with transient wall motion abnormalities without a culprit coronary stenosis or other concurrent diagnoses. Its coexistence with transient high-degree AV block is very infrequent.

Case presentation

A 61-year-old man presented with a new onset of high degree AV block without ST segment deviations developing an anterior and apical dyskinesia with a low left ventricular ejection fraction in the absence of coronary artery disease.

Conclusion

Atrioventricular block is an uncommon presentation of Takotsubo syndrome. The management of patients with relevant conduction disorders in this scenario is a challenge for the clinician. In case of persistence of advanced conduction disorders, it seems appropriate to implant a pacemaker.

Complete Heart Block Complicating Takotsubo Syndrome: Case Report and Literature Review

An 81-year-old woman presents with shortness of breath resulting in a diagnosis of picornavirus and complete heart block. Troponin was elevated and there was concern about acute coronary syndrome. The final diagnosis after echocardiogram and coronary angiogram was Takotsubo syndrome in addition to the heart block which required pacemaker insertion.

Comparison of Complications and In-Hospital Mortality in Female Patients with Takotsubo Syndrome and ST-Segment Elevation Myocardial Infarction

BACKGROUND

Takotsubo syndrome (TTS) is a clinical condition that mimics acute myocardial infarction (MI). More than 90% patients are women, mainly postmenopausal. Research suggests that up to 5% of women evaluated for a MI actually have TTS and that diagnose may be underestimated. Patients with TTS are generally able to fully recover within a period of days to weeks. However, serious, potentially fatal, complications may occur.

METHODS

In 117 consecutive female patients hospitalized with TTS and 117 consecutive female patients with ST-segment elevation MI, we collected data regarding cardiovascular risk factors, comorbidities, and complications. We compared all in-hospital complications in both groups and analyzed factors influencing the composite endpoint which was cardiogenic shock and death from any cause.

RESULTS

In our study patients with TTS had a lower incidence of serious complications compared to the ST-segment elevation MI group. Moreover, in-hospital mortality was also lower in the TTS group. The factors which influenced cardiogenic shock and death from any cause were: heart rate at admission, diastolic blood pressure at admission, C-reactive protein (CRP) concentration at admission, chest pain at admission, ST-segment depression in the electrocardiography at admission, and ejection fraction at admission. Moreover, patients with exacerbation of chronic disease as the cause of TTS also reached the composite endpoint more often.

CONCLUSIONS

Female patients with TTS had more favorable in-hospital prognoses than patients with ST-segment elevation MI. However, serious complications occurred. The factors which influenced the composite endpoint came from readily available data-within the first hour after admission to the hospital.

Takotsubo Cardiomyopathy Presenting with Sinoatrial Disease: A Rare Presentation

Takotsubo cardiomyopathy (TCM), or apical ballooning syndrome, is a distinct nonischemic cardiomyopathy mimicking acute coronary syndrome. A 76-year-old female presented with ST elevation in the inferior lead and a troponin level of 0.81 ng/dL. An immediate coronary angiography showed non-obstructive coronary artery disease. A subsequent ventriculogram and echocardiogram showed anteroapical and distal inferior wall hypokinesis suggestive of TCM. Despite therapy with beta blocker, she was observed to have two significant sinus pauses, one eight-second, and a second 29-second pause. An urgent transvenous pacemaker was put in place and later followed by a permanent pacemaker. The patient was discharged on carvedilol and losartan. Although other arrhythmias such as complete heart block, torsades, and ventricular arrhythmias have been commonly reported, the association of TCM with recurrent sinus arrest has rarely been reported in the literature. The occurrence observed in this case implies that patients with TCM should be monitored closely for arrhythmias, and, if such a condition is identified, planning for permanent pacemaker implantation should be started early enough to avoid recurrent life-threatening episodes.

An unusual case of complete atrioventricular block causing Takotsubo syndrome

Complete atrioventricular (AV) block in association with Takotsubo syndrome (TS) has been well recognized, but the cause and effect relationship has not been elucidated. We describe a 78-year-old female who presented with complete AV block but one week later developed new-onset, diffuse T-wave inversions, QT prolongation, and acceleration of junctional escape rate. Left ventriculogram revealed features typical of TS. One year after permanent pacemaker implantation, complete AV block persisted despite the reversal of wall motion defects implying that conduction abnormality was the trigger of TS rather than its consequence.

Takotsubo cardiomyopathy-related complete heart block and torsades de pointes

Takotsubo cardiomyopathy (TCM) is a relatively recently recognised clinical entity. It frequently mimics acute coronary syndrome and is accompanied by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis. TCM is a reversible condition, and the prognosis is usually well. However, in rare instances, it can be associated with life-threatening arrhythmic complications. Herein, we report the case of a patient with TCM who developed complete atrioventricular block followed by QT prolongation and torsades de pointes. Furthermore, we undertook a literature review of this rare complication of TCM and discussed the formidable therapeutic challenge encountered in such patients.

Reversibility of High-Grade Atrioventricular Block with Revascularization in Coronary Artery Disease without Infarction: A Literature Review

Complete atrioventricular (AV) block is known to be reversible in some cases of acute inferior wall myocardial infarction (MI). The reversibility of high-grade AV block in non-MI coronary artery disease (CAD), however, is rarely described in the literature. Herein we perform a literature review to assess what is known about the reversibility of high-grade AV block after right coronary artery revascularization in CAD patients who present without an acute MI. To illustrate this phenomenon we describe a case of 2 : 1 AV block associated with unstable angina, in which revascularization resulted in immediate and durable restoration of 1 : 1 AV conduction, thereby obviating the need for permanent pacemaker implantation. The literature review suggests two possible explanations: a vagally mediated response or a mechanism dependent on conduction system ischemia. Due to the limited understanding of AV block reversibility following revascularization in non-acute MI presentations, it remains difficult to reliably predict which patients presenting with high-grade AV block in the absence of MI may have the potential to avoid permanent pacemaker implantation via coronary revascularization. We thus offer this review as a potential starting point for the approach to such patients.

Mechanisms of stress (takotsubo) cardiomyopathy

Stress cardiomyopathy is a form of reversible systolic dysfunction of the mid and apical left ventricle with pathologic changes of the electrocardiogram in the absence of an obstructive coronary artery disease. The prevalence of stress cardiomyopathy among patients with symptoms suggestive of myocardial infarction is 0.7% to 2.5%, and it is found predominantly in postmenopausal women (90%). No large studies have confirmed the cause of stress cardiomyopathy. Published data suggest that substantially elevated plasma catecholamine levels, due to emotional or physical stress, may be relevant.

An uncommon presentation of a rare disease - high-degree AV block with takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a type of non-ischemic cardiomyopathy in which there is sudden temporary left ventricular dysfunction. High-degree AV block and takotsubo cardiomyopathy have been reported together rarely in medical literature. Here we discuss a case of takotsubo cardiomyopathy presenting with complete heart block. A 72-year-old female presented with retrosternal chest pain. Electrocardiogram showed complete heart block without any significant ST-T changes. Echocardiogram revealed regional wall motion abnormality not consistent with coronary artery disease and was suggestive of apical ballooning. Coronary angiogram showed no significant coronary artery lesion. LV angiogram showed apical ballooning and LV systolic dysfunction. Patient underwent temporary pacemaker implantation. Since the complete heart block did not revert even after 18 days, she underwent a permanent pacemaker implantation.

Takotsubo cardiomyopathy--a clinical review

Stress cardiomyopathy is characterised by reversible left ventricular dysfunction. It simulates an acute coronary syndrome (ACS), presenting with precordial pain or dyspnoea, changes of the ST segment, T wave, or QTc interval on electrocardiogram, and raised cardiac enzymes. Typical findings are disturbances of segmental contractility (apical hypokinesia or akinesia), with normal epicardial coronary arteries. The true prevalence is unknown, as the syndrome may be under-diagnosed; it is more common in postmenopausal women. There is usually a trigger in the form of physical or psychological stress. The electrocardiographic, echocardiographic, and ventriculographic changes resolve spontaneously over a variable period of time (from days to months). There are a number of pathophysiological theories, none of which has been shown to be definitive, suggesting that all of them may be involved to some extent. The prognosis is generally favourable, and recurrence is very rare.

Mechanisms of stress (Takotsubo) cardiomyopathy

Stress cardiomyopathy, also referred to as Takotsubo cardiomyopathy, transient apical ballooning or broken heart syndrome, is a disorder associated with transient left ventricular dysfunction. Symptoms include acute chest pain and dyspnea accompanied by electrocardiographic changes, such as ST-segment elevation and T-wave inversions, minimal elevation of cardiac enzyme levels and transient wall-motion abnormalities in the absence of substantial coronary artery obstruction. Complete recovery of contractile function has been documented in nearly all cases, but the mechanisms of disease remain unclear and the cause has not been established. Coronary artery vasospasm, microcirculation dysfunction, and transient obstruction of the left ventricular outflow tract have been proposed as possible causes of this disorder. An excessive release of catecholamines also seems to have a pivotal role in the development of stress cardiomyopathy. This Review summarizes published data on stress cardiomyopathy, focusing primarily on the most likely causes of this cardiac entity.

Out-of-hospital cardiac arrest caused by transient left ventricular apical ballooning syndrome

We describe a case of out-of-hospital cardiac arrest due to ventricular fibrillation in a patient with transient left ventricular apical ballooning syndrome. Our report confirms that left ventricular apical ballooning may have the same complications of myocardial infarction, adding the early ventricular fibrillation to the previous findings of left ventricular wall rupture, ventricular arrhythmias during hospitalization and complete atrio-ventricular block. Moreover, left ventricular apical ballooning may have different and unusual clinical onsets, including sudden cardiac death due to ventricular tachyarrhythmias in the absence of associated symptoms. Therefore, in our opinion left ventricular apical ballooning may be considered as a possible cause of sudden death in otherwise healthy women.