Takotsubo cardiomyopathy with severe bradyarrhythmia following epidural insertion

Abstract

We present a case of takotsubo cardiomyopathy (TTC) with ventricular stand still and atrioventricular block. TTC can mimic ST elevation myocardial infarction and heart failure, but in this case resulted in a severe cardiac conduction disorder and ventricular standstill. This is a recognised but unusual presentation and serves as a lesson to those undertaking anaesthetics to be vigilant for TTC.

Atrio‐ventricular block and takotsubo syndrome: A review illustrated with two case reports

“…Cases of AV‐block preceding or occurring in association with the onset of TS have been reported 8‐10 . The common features of all these cases are the apical or mid‐ventricular pattern of TS sparing the basal segments of the LV and the AV‐block persisted after complete resolution of the LV‐dysfunction, which argues for the fact that AV‐block triggered TS just like the 2 cases we have described.…”

“…TS may be complicated by transient but prolonged AV‐block. Cases with TS and transient AV‐block treated by temporary pacemaker implantation have been reported 5‐13 . A case of TS and AV‐block where AV‐block persisted for 2 weeks resulting in permanent pacemaker implantation 13 .…”

Takotsubo syndrome‐associated ventricular standstill in a peripartum patient: case report and review of the literature

“…Ultimately, persistent spasms of multiple‐branch coronary arteries may lead to continuous ischemic damage and eventual conduction pathway fibrosis leading to rapid deterioration of the cardiac conduction system and an impaired ability to communicate electrical impulses through the circuit. In our patient, serum troponins were elevated suggesting underlying ischemic damage .…”

“…Literature review revealed only one other documented case of TTS with ventricular standstill in a 66‐year‐old patient who was believed to have had TTS secondary to epidural placement prior to surgery for an adrenal mass . The pathophysiology of bradyarrhythmias in TTS is still unclear, although several proposed mechanisms include reduced coronary blood flow to conduction pathways secondary to ventricular dyskinesia, catecholamine‐induced coronary vasospasm, and conduction pathway fibrosis secondary to prolonged ischemia . Due to the presence of ventricular standstill and bifascicular block in our patient, a permanent pacemaker was deemed necessary to minimize the risk of death caused by fatal arrhythmias.…”

Acute arterial occlusion due to left ventricular thrombus of Takotsubo cardiomyopathy in a young adult: a case report

“…Therefore, the case reported here was not at a common age for development of Takotsubo cardiomyopathy. However, given that there are several reports of Takotsubo cardiomyopathy developing perioperatively [7,8], anesthesiologists must be prepared to provide appropriate management such as trans esophageal echocardiography and/or regional cerebral oxygen saturation monitoring. In approximately 85% of acute arterial embolism cases, occlusion is caused by emboli from a cardiac source [9], including atrial fibrillation associated with valvular heart disease or mural thrombi in an infarcted left ventricle.…”