Takotsubo Cardiomyopathy-Induced Conduction System Quiescence With Concomitant Fascicular Ventricular Tachycardia and Complete Heart Block.

BACKGROUND

Takotsubo cardiomyopathy (TCM) is a stress-induced cardiomyopathy that mimics acute coronary syndrome without obstructive coronary artery disease. Complications include persistent, life-threatening arrhythmias, even after ejection fraction recovery.

CASE SUMMARY: A 73-year-old woman presented with syncope, and electrocardiogram showed alternating wide complex tachycardia and complete heart block (CHB) (heart rate: 30-150 beats/min). Transthoracic echocardiography showed a left ventricular ejection fraction of 15% with apical/mid akinesis and basal hyperkinesis, and left heart catheterization showed nonobstructive coronary artery disease. Persistent ventricular tachycardia and CHB precluded antiarrhythmic therapy. After failing biventricular capture given an electrically quiescent conduction system, a dual-chamber implantable cardioverter-defibrillator was placed.

DISCUSSION: Catecholamine excess in TCM induces microvascular dysfunction, leading to both tachy- and bradyarrhythmias, likely from catecholamine-induced electrical instability and concomitant vagal stimulation. Although most arrhythmias in TCM are transient, CHB requires permanent pacing, suggesting residual electrical remodeling despite ejection fraction recovery and highlighting a potential role for autonomic modulators.

TAKE-HOME MESSAGE: TCM causes reversible left ventricular dysfunction, but persistent conduction disease highlights the need for intervention and device implantation, and further study is needed to guide pacing strategies.