Atypical presentation of Takotsubo syndrome early after pacemaker implantation

Aims: Takotsubo syndrome (TTS) is an acute stress-induced cardiomyopathy showing
left ventricular (LV) dysfunction without obstructive coronary arteries disease. A sudden
massive surge of circulatory catecholamines from an intense physical or
emotional stress may play a central role in the pathogenesis of TTS. We report the
case of an 87 years-old woman who developed TTS with uncommon presentation after
permanent pacemaker (PM) implantation.
Methods and results: The patient was referred to our hospital for PM implantation because
of advanced atrio-ventricular block (3:1). She suffered by rheumatoid arthritis
(RA), arterial hypertension, and chronic kidney disease. Echocardiogram, performed before
PM implantation, showed normal LV kinesis and normal ejection fraction (EF 60%).
She was initially administered with infusion of Isoprenaline 2mcg/min. The subsequent
day, she underwent permanent dual-chamber pacemaker implantation without any complications.
After 3 days, the patient complained severe asthenia and fever, together
with increase of white blood cells and C reactive protein. Blood cultures were negative.
We started antibiotic therapy and, suspecting a reactivation of RA, steroid therapy with
infusion of methylprednisolone 40mg/die. Electrocardiogram showed normal sinus
rhythm and paced ventricular rhythm. PM interrogation showed normal function.
Surprisingly, echocardiogram showed LV dysfunction with apical and medium segments
akinesia, and severe EF reduction (35%). Coronary angiography documented absence of
coronary obstructive lesions, assessing diagnosis of TTS. The patient was discharged 1
week after admission in good clinical condition. One week later, an echocardiogram
showed apical akinesia, partial recovery of medium segments motility, and slight increase
of EF (40%). The excess of catecholamines could lead to decreased cardiac
muscular function and to spasm of coronary arteries: these events can lead to acute
heart failure and decrease of LVEF. Furthermore, about 90% of patients with TTS are
women, especially in postmenopausal period. Peculiarities of this case were the atypical
symptoms of TTS and the combination of different predisposing stressors factors: female
sex in postmenopausal period, anamnesis of chronic inflammatory disease, use of stressinducing
drugs (methylprednisolone and isoprenaline, the last associated with TTS after
PM-implantation), atrio-ventricular block itself, and PM implantation procedure. Our
findings remark that even a low-risk procedure could be a possible cause of TTS in patient
with such risk factors. In our opinion, in this subset of patients, conscious sedation
could be useful to reduce the stress load, together with an early procedure and consequently
the minimal use of exogenous stress drugs like Isoprenaline, even if the patient
is in a good clinical condition.
Conclusions: This case highlights TTS as a potential complication after PM implantation,
especially in post-menopausal women with high pre-existing stress load.