Combined exogenous and endogenous catecholamine release associated with Tako-Tsubo like syndrome in a patient with atrio-ventricular block undergoing pace-maker implantation

An Electrifying Case of a Broken Heart Syndrome

Takotsubo syndrome (TTS) describes an acute and transient left ventricular (LV) dysfunction that, although not obligatory, is many times associated with an underlying emotional, physical, or combined trigger. We describe a rare case of an 80-year-old female who developed TTS after pacemaker implantation in the context of a complete atrioventricular block (CAVB). During the patient's workup, right ventricular (RV) lead dislodgment was found. She developed acute heart failure symptoms 12 hours after device implantation with transthoracic echocardiogram showing de novo severe systolic biventricular dysfunction with dyskinesia of the apical segments and hyperdynamic contractility of the basal segments of both ventricles. Coronarography was normal, and left ventriculography demonstrated apical ballooning. TTS was then considered the most probable diagnosis. The patient received supportive care with diuretics, beta-blocker, and angiotensin-converting enzyme inhibitor (ACEI); an RV lead repositioning was also done. After four weeks, left ventricular function had fully recovered, confirming the diagnosis. This is a rare case of a post-pacemaker implantation TTS with concomitant lead dislodgment that can be assumed as a likely contributing factor. This report emphasizes that, although rare, TTS should be considered in the differential diagnosis of patients with acute heart failure development after pacemaker implantation.

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.

Takotsubo Cardiomyopathy in a Nonagenarian With Urosepsis

Takotsubo cardiomyopathy (TCM) is a rare but reversible myocardial left ventricular (LV) dysfunction, which mimics acute coronary syndrome (ACS) without the presence of significant coronary artery disease (CAD). Emotional stressors may include the death of kin or a life-threatening medical diagnosis whereas physical stressors include infections, endoscopic procedures, exacerbation of asthma, or systemic disorders. A 90-year-old female presented to the ED with nausea, intermittent chest heaviness, and generalized weakness for a duration of three days. Her troponin-I was elevated and an electrocardiogram (EKG) showed T-wave inversions in leads V2-V6 and no ST-segment changes. An echocardiogram (ECHO) revealed an ejection fraction (EF) of 35%-40% with anteroapical hypokinesis. She underwent cardiac catheterization showing nonobstructive CAD. She was diagnosed with pan-sensitive Escherichia coli urosepsis and started on ceftriaxone. She improved clinically and was discharged. A repeat ECHO done a month later showed normal EF. Urosepsis-induced TCM has rarely been reported in the literature. Physicians should have a high index of suspicion of TCM in patients with symptoms mimicking ACS in the presence of a physical stressor like an infection. We report the case of TCM, which resulted from a urinary tract infection (UTI) in an elderly female.

Delayed ventricular pacing failure and correlations between pacing thresholds, left ventricular ejection fraction, and QTc values in a male with Takotsubo cardiomyopathy

BACKGROUND

Transient pacing failure caused by transient increased pacing threshold has been reported in patients with transient left ventricular apical dysfunction (Takotsubo cardiomyopathy [TC]). Normal pacing thresholds usually recover after normalization of systolic dysfunction.

HYPOTHESIS

Pacing failure correlates with clinics of TC.

METHODS

We report the case of a 76-year-old man with a dual chamber pacemaker, admitted for acute chest pain and dyspnea and final diagnosis of TC. One month after index admission, the patient came back complaining again of chest pain. Unexpectedly, admission electrocardiogram showed ventricular pacing failure and an increased pacing threshold. In the following weeks, pacing threshold gradually recovered with left ventricular ejection fraction and QTc values.

RESULTS

Ventricular pacing threshold correlated directly to QTc values and inversely to left ventricular ejection fraction over time (P < 0.05).

CONCLUSIONS

This is one of the first cases of delayed transient ventricular pacing failure in a male patient with transient left ventricular apical ballooning, in the presence of spared right ventricular function. Given the possibility of acute transient anomalies in myocardial impedance and pacing failure even in the subacute phase of TC several weeks after clinical onset of transient systolic dysfunction, pacing threshold should be carefully monitored in subjects with TC, both during the acute phase of the disease and in first months of follow-up after discharge. Ventricular pacing threshold correlated directly to QTc values and inversely to left ventricular ejection fraction over time.

Sick Sinus Syndrome and Takotsubo Cardiomyopathy

Background. Takotsubo cardiomyopathy is associated with increased risk of ventricular arrhythmias, atrial fibrillation, and bradyarrhythmias. However, sinus node dysfunction is relatively infrequent in the setting of takotsubo cardiomyopathy. Case Report. We are reporting a case of a 73-year-old woman with a history of asymptomatic sinus bradycardia who developed sick sinus syndrome complicated by takotsubo cardiomyopathy. Conclusion. Acute symptomatic sick sinus syndrome in patients with preexisting silent sinus node dysfunction can trigger takotsubo cardiomyopathy. Understanding precipitating factors of takotsubo cardiomyopathy and identifying the patients at risk of life-threatening arrhythmia can help in refining risk stratification and therapy planning. Patients with sick sinus syndrome complicated by takotsubo cardiomyopathy may benefit from pacemaker implantation. However, evaluation on a case-by-case basis is mandatory.

Early recurrence of Tako-Tsubo cardiomyopathy in an elderly woman with amyotrophic lateral sclerosis: different triggers inducing different apical ballooning patterns

: We report the case of early recurrence of Tako-Tsubo cardiomyopathy in an elderly woman with amyotrophic lateral sclerosis triggered by different stressors. A first episode with typical apical ballooning was anticipated by an emotional stress; a second, characterized by systolic anterior motion of the mitral valve associated with mitral regurgitation and severe intra-ventricular gradient, was precipitated by surgical stress and hypovolemia. We therefore hypothesize both a possible link between amyotrophic lateral sclerosis and Tako-Tsubo cardiomyopathy, and between different stressors and different Tako-Tsubo patterns.

Takotsubo cardiomyopathy secondary to spontaneous right-sided pneumothorax

Takotsubo cardiomyopathy (TCM) is a unique type of cardiomyopathy characterised by left ventricular systolic dysfunction in association with stressful conditions. Patients with this condition usually present with chest pain and dyspnoea, and the presentation can mimic acute coronary syndrome. We present a case of a woman aged 58 years who presented with progressive dyspnoea and cough. Her initial evaluation was suggestive of acute myocardial infarction with elevated serum troponin T and ST segment elevation. Her chest radiograph showed a large right-sided pneumothorax, which was treated with chest tube insertion. Coronary angiography and echocardiogram did not show any evidence of obstructive coronary artery disease but did show a large area of akinesis consistent with TCM. The patient was managed medically with supportive care. Her pneumothorax resolved, and her follow-up echocardiogram also showed improvement. The association between pneumothorax and TCM is rare, and only four other cases have been reported so far in the English literature.

Tako-Tsubo cardiomyopathy complicated by paroxysmal supraventricular tachycardia

: We report a case of paroxysmal supraventricular tachycardia complicating Tako-Tsubo cardiomyopathy. We hypothesize that increased adrenergic tone supposedly underlying transient apical ballooning syndrome may facilitate the onset of paroxysmal supraventricular tachycardias in predisposed patients.

Stress-induced cardiomyopathy following infection of the upper respiratory tract in an elderly female patient: A case report

Stress-induced cardiomyopathy (SIC), also known as takotsubo cardiomyopathy (TTC), is a relatively newly-described condition, which has been increasingly reported in the literature. It is characterized by acute onset of symptoms and electrocardiogram changes mimicking myocardial infarction, with transient but completely reversible left ventricular (LV) dysfunction. SIC commonly occurs following physical or emotional stress. The present study discusses the case of a 68-year-old female patient who had suffered from infection of the upper respiratory tract for 10 days before admission to the hospital with symptoms of chest stuffiness and dyspnea that persisted for 2 days. Coronary angiography showed normal coronary artery function, while LV angiography demonstrated systolic apical ballooning. Based on these observed characteristics, the patient was diagnosed with SIC and was successfully treated.

Takotsubo cardiomyopathy shortly following pacemaker implantation-case report and review of the literature

We describe a patient with acute heart failure shortly after pacemaker implantation. With the documentation of typical dyskinesia of the apical segments with hyperdynamic contractility of the basal segments and a normal coronary angiogram, pacemaker implantation-induced Takotsubo cardiomyopathy was diagnosed. Supportive care was administered and within several days the patient's symptoms resolved. After several weeks, the left ventricular function had fully recovered. A review of the literature on Takotsubo cardiomyopathy after pacemaker implantation is presented.

Safety and feasibility of levosimendan administration in takotsubo cardiomyopathy: a case series

BACKGROUND

Levosimendan is a noncatecholamine inotrope that does not increase oxygen consumption, utilized for the treatment for acute heart failure with left ventricular (LV) systolic dysfunction. Its use in takotsubo cardiomyopathy (TTC), a disease that contraindicates the use of catecholamine inotropes, is not well known.

METHODS

We prospectively analyzed 13 consecutive patients with TTC, low ejection fraction (EF) (<35%), and additional Mayo Clinic risk factors who were treated with i.v. infusion of levosimendan. Clinical course of patients, electrocardiogram presentation, LV function, and adverse events at follow-up were recorded.

RESULTS

All patients showed an impaired LV function (LVEF at admission 28 ± 5%), which significantly improved at discharge (51 ± 8%, P < 0.001). Mean hospital stay was 10 ± 4 days. Troponin levels at admission were directly related to length of hospitalization (r = 0.6, P < 0.001). Male gender (relative risk (RR) 1.85, P < 0.05), physical stress (RR 1.90, P < 0.05), ST elevation at ECG (RR 1.87, P < 0.05), and absence of chest pain (RR 2.23, P < 0.01) were found to be the predictors of longer hospital stay. Only 15% of subjects had adverse events during hospital stay; two patients incurred noncardiovascular death at follow-up. Age was the only predictor of adverse event at follow-up (RR 2.13, P < 0.05).

CONCLUSIONS

The use of levosimendan may be safe and feasible in patients with TTC. Randomized studies are warranted to further confirm these preliminary results.

Potential links between neurological disease and Tako-Tsubo cardiomyopathy: a literature review

Tako-Tsubo cardiomyopathy (TTC), is defined as a fully reversible acute deterioration of left-ventricular (LV) function, which is mainly found in women after an episode of emotional or physical stress (e.g. psychosocial stress, sepsis, surgery). The underlying mechanisms remain unclear. There is evidence suggesting a possible link between neurological disease and TTC. The pathophysiology of the several neurologic diseases has been reviewed searching for possible mechanisms that could lead to TTC in these patients.