Takotsubo Cardiomyopathy Associated with High-Grade Atrioventricular Block and Ventricular Fibrillation: A Case Report

Figures & data

Figure 1 12-Lead ECG (A) at admission showing incomplete right branch block, left anterior-superior divisional block, left axis deviation of the QRS, 2:1 AV block, corrected QT interval prolongation (689ms) and inverted T waves; (B) at discharge showing resolution of T wave inversions and shortening of the QT interval after pacemaker implantation.

Figure 2 Transthoracic echocardiographic 4-chamber view of the left ventricle in diastole (A) and in systole (B) shows basal hypercontractility (green arrow) and midapical ballooning (yellow arrow).

Abbreviations: LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Figure 3 Cardiac magnetic resonance 4-chamber view of the left ventricle in diastole (A) and in systole (B) showing hypercontractility (green arrow) and typical apical ballooning (yellow arrow) in takotsubo syndrome.

Abbreviations: LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle.

Box 1 Learning Points

1. The presence of arrhythmias in patients with TCM is uncommon, and high-grade AV block is associated with high morbidity and mortality.

2. The exact association between AV block and TCM is not clear, but it can be explained by the continual ischemic status due to the microvascular dysfunction.

3. TCM usually reverses completely, but AV block may persist in spite of complete clinical recovery.

4. Patients with high-grade AV block and TCM, especially those with prolonged QT interval, require a temporary pacemaker due to the high risk of malignant ventricular arrhythmias.

5. The time required for the indication of the definitive pacemaker is not yet clear. Because the likelihood of AV block reversal is low, we believe that the time between symptom onset up to 14 days is adequate.

6. The choice of pacemaker (dual chamber versus biventricular) in patients with left ventricular dysfunction (LV) due to TCM is not clear. Because LV dysfunction is reversible in most patients with TCM, a dual chamber pacemaker may be preferable to a biventricular pacemaker.