Complete Atrioventricular Block Associated With Takotsubo Cardiomyopathy

Abstract

Circ J 2009; 73: 589 -592 ransient left ventricular dysfunction with chest symptoms and electrocardiographic (ECG) changes mimicking those of acute myocardial infarction are known as takotsubo cardiomyopathy. [1][2][3] Although the pathogenesis of takotsubo cardiomyopathy remains unclear, physical or emotional stress is common and elevation of plasma catecholamines suggests that sympathetic stimulation plays a central role. When medical support is provided promptly, the long-term prognosis of takotsubo cardiomyopathy is generally good with full recovery of left ventricular contraction. Patients with takotsubo cardiomyopathy generally show T-wave inversion and QT-prolongation during the early phase, and these ECG changes typically normalize within several weeks with improvement of left ventricular wall motion. [1][2][3] The arrhythmias associated with takotusbo cardiomyopathy include atrioventricular (AV) block, sinus bradycardia, paroxysmal atrial fibrillation, ventricular tachycardia and ventricular fibrillation. [2][3][4][5][6][7][8][9] Here, we describe a case of takotsubo cardiomyopathy demonstrating persistent complete AV block after improvement of left ventricular wall motion that needed the implantation of a pacemaker. Case ReportAn 82-year-old woman with no history of cardiac disease or hypertension presented to the emergency department due to repeated episodes of syncope with incontinence. She had been stressed for about 2 weeks and could not sleep well because she was caring for her grandchildren who had been injured in a traffic accident. The patient had taken care of her grandchildren over the night before admission and complained of fatigue but denied chest pain. There was no family history of heart disease or sudden death. She had no history of arrhythmia or prior syncope. On admission her blood pressure was 110/72 mmHg, the pulse was 38 beats/min and body temperature was 35.6ºC. Her consciousness was clear, and a neurological examination revealed no neurological deficits. She had a repeated syncope lasting for about 10 s presenting torsades de pointes on monitoring ECG in the emergency department. The 12 leads ECG on admission showed complete AV block, diffuse T-wave inversions in leads I, aVL, V2-6 and prolonged QTc interval of 630 ms (Figure 1). Chest X-ray showed mild cardiomegaly and no pulmonary congestion. The laboratory data on admission are shown in Table 1. The serum level of creatine kinase was normal, but the rapid cardiac Troponin T assay was positive. Serum electrolytes, plasma norepinephrine and adrenaline levels were within the normal range. An elevated plasma level of brain natriuretic peptide suggested cardiac dysfunction. Echocardiography revealed akinesis in the left ventricular apical wall and no pericardial effusion. A temporary transvenous pacemaker was inserted due to complete AV block and to prevent the recurrence of torsade de pointes. Urgent coronary angiography was carried out and showed no significant coronary stenosis or vascular obstruction. Left ventriculography ...

Midventricular Ballooning Takotsubo Cardiomyopathy Complicated by Transient Complete Atrioventricular Block

“…Takotsubo cardiomyopahty often presents with abnormal findings on electrocardiography that mimic coronary artery disease and are occasionally complicated by various arrythmias (2,(6)(7)(8). Although the present patient did not exhibit typical ST-T changes or prolongation of the QT interval on the electrocardiograms, transient complete AV block was a complicating finding.…”

“…Indeed, syncope caused by complete AV block was observed in our emergency room. Several cases have been reported in which a permanent pacemaker was implanted due to bradyarrhythmia associated with Takotsubo cardiomyopathy that persisted even after improvements in left venticular wall motion (7,8). However, the AV block observed in the present case was transient, and the electrophysiological study performed on day 13 showed normal findings, indicating that the AV block was functional and permanent pacemaker implantation was not indicated.…”

Torsades de Pointes in Takotsubo Cardiomyopathy with QT Prolongation

“…The presence of QT interval prolongation has been discussed in patients with Takotsubo cardiomyopathy (Abe et al, 2003, Desmet et al, 2003, Matsuoka et al, 2003, and there have been 17 reported cases of QT interval prolongation and torsades de pointes (TdP) associated with Takotsubo cardiomyopathy (Denney et al, 2005, Sasaki et al, 2006, Okada T, et al, 2007in Japanese], Nault et al, 2007, Boulouffe et al, 2007, Patel et al, 2007, Kurisu et al, 2008, Furushima et al, 2008, Hirose et al, 2008, Ghosh et al, 2009, Mahida et al, 2009, Inoue et al, 2009, Kawano et al, 2010, Purvis et al, 2009, Yamada et al, 2011 (Figure 2) (Table 1). Considering the 17 previous cases reported in the literature, QT prolongation in Takotsubo cardiomyopathy has been attributed to hypokalemia (n= 3), bradycardia associated with atrioventricular (AV) block (n=4), idiopathic long QT syndrome (n=2), hypokalemia plus antiarrhythmic therapy (n=1), and hypokalemia plus idiopathic long QT syndrome (n=1), hypokalemia and hypomagnesemia (n=1), hyponagnesemia (n=1), and antibiotic (n=1) in 14 cases, and there was no specific factor associated with QT prolongation in 3 cases.…”

Torsades de Pointes Associated with Takotsubo Cardiomyopathy: Is It Preventable?

“…Takotsubo cardiomyopathy-associated Torsades de Pointes has been reported in 2005 for the first time (Denney et al, 2005). We have reviewed this case report and additional 14 reports (Akashi et al, 2003;Boulouffe et al, 2007;Finsterer et al, 2007;Furushima et al, 2008;Ghosh et al, 2009;Hirose et al, 2008;Inoue et al, 2009;Kurisu et al, 2008;Mahida et al, 2009;Nault et al, 2007;Okada et al, 2007;Patel et al, 2007;Sasaki et al, 2006) concerning Takotsubo cardiomyopathy-associated Torsades de Pointes in 2009, and we have concluded that males with Takotsubo cardiomyopathy-associated QT interval prolongation are at risk for Takotsubo cardiomyopathy-associated Torsades de Pointes although most patients with Takotsubo cardiomyopathy are females. There has been a trend in the mean maximal QT interval being longer among patients with Takotsubo cardiomyopathy-associated Torsades de Pointes relative to patients with Takotsubo cardiomyopathy-associated QT interval prolongation.…”