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Takotsubo syndrome, complete heart block and cardiac arrest – a clinical challenge
Session:
CASOS CLÍNICOS DE ARRITMOLOGIA
Speaker:
Ana Lobato De Faria Abrantes
Congress:
CPC 2025
Topic:
C. Arrhythmias and Device Therapy
Theme:
04. Arrhythmias, General
Subtheme:
04.6 Arrhythmias, General – Clinical
Session Type:
Sessão de Casos Clínicos
FP Number:
---
Authors:
Ana Lobato de Faria Abrantes; Catarina Gregório; Miguel Azaredo Raposo; João Fonseca; Diogo Ferreira; Marta Vilela; Diogo Ferreira; Nelson Cunha; Fátima Veiga; Mónica Mendes Pedro; Dulce Brito; Fausto J. Pinto
Abstract
<h5 style="text-align:justify"><span style="font-size:12pt"><span style="font-family:'Times New Roman',serif"><span style="color:#000000">Introduction: Complete atrioventricular block (cAVB) may be associated with Takotsubo syndrome (TTS) and the decision of device implantation in such patients is challenging.</span></span></span></h5> <h5 style="text-align:justify"> </h5> <h5 style="text-align:justify"><span style="font-size:12pt"><span style="font-family:'Times New Roman',serif"><span style="color:#000000">Case presentation: A 76 year old woman was admitted after resuscitation from cardiac arrest in a shockable rhythm. No previous symptoms were reported. Patient's medical history included hypertension and dyslipidemia treated with indapamide, amlodipine and simvastatin. On admission she was conscious, with no signs of congestion or malperfusion. Post-resuscitation ECG showed cAVB with a heart rate of 41 bpm. Laboratory analysis showed hypokalemia (2.9mmol/L), elevated troponin (82 ng/L) and marked elevation of NTproBNP (4890 pg/mL). Echocardiogram revealed apical hypokinesis with hypercontractility of basal segments with severe left ventricular dysfunction (EF of 30%). A transitory pacemaker (PMK) was placed and coronarography excluded coronary disease. On day 4, QT interval prolonged and T waves inverted in precordial leads. Cardiac magnetic resonance, on day 14, showed hypokinesia, oedema in T2 mapping of apical segments, normal EF and no gadolinium uptake, consistent with subacute TTS. After exclusion of prevalent causes, hypokalemia was considered to be indapamide induced. cAVB persisted despite improvement of LV function and normalization of kalemia. A PMK was implanted on day 18. During a follow-up of 24 months, the patient remained asymptomatic with normal troponin, NTproBNP and recovery of left ventricular function and wall motion abnormalities. PMK interrogation showed 99% of ventricular pacing (70% atrial sensing, 30% atrial pacing).</span></span></span></h5> <p> </p> <p style="text-align:justify"><span style="font-size:11pt"><span style="font-family:Arial,sans-serif"><span style="color:#000000">Discussion: </span></span></span><span style="font-size:12pt"><span style="font-family:'Times New Roman',serif"><span style="color:#000000">The association of TTS with AVB or cardiac arrest (CA) has been reported in 2.9% and 5.9% of patients (pts), respectively, however, it is impossible to determine whether CA itself induces TTS or if TTS promotes an arrhythmogenic substrate to CA. Given the reversible nature of TTS the implantation of cardiac devices in acute phase is controversial. However most pts with TTS are old and prone to AV conduction disturbance. Most cases report that AVB in pts with TTS usually persists despite ventricular dysfunction recovery. In this case, our pt had substrate for degenerative conduction abnormalities, and AVB persisted despite correction of hypokalemia, normalization of cardiac biomarker, wall motion and function.Therefore we consider that cAVB was the primordial event that complicated with shockble rythme, flowed by CA, acting as physical stressors that lead to TTS.</span></span></span></p> <p> </p> <p style="text-align:justify"><span style="font-size:12pt"><span style="font-family:'Times New Roman',serif"><span style="color:#000000">Conclusions: cAVB can be the initial manifestation of TTS. Persistence of conduction abnormalities despite reversal of ventricular defects supports that the stress of AVB may trigger TTS. In such patients pacemaker implantation may be needed and the decision should be individualized. Further evidence is needed for better patient management.</span></span></span></p> <p> </p>
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