Takotsubo Syndrome After Additional Right Ventricular Lead Insertion in a Pacemaker User

An 88-year-old woman, who had undergone pacemaker implantation for complete atrioventricular block 12 years prior (Figure A), received an additional right ventricular (RV) lead insertion due to an existing lead subfracture (Figure B). Although the procedure, in which a screw-in lead was placed in the mid-septum under local anesthesia, was successful and uneventful, the patient complained of sudden nausea at 30 min postoperatively. Electrocardiography revealed no myocardial ischemia (Figure C), but an akinesis from the anteroseptal to the apical left ventricular (LV) wall was observed. Coronary computed tomography (CCT) revealed no significant coronary lesion (Figure D), but revealed apical akinesia with hypercontractile basal segments (Figure E–H; Supplementary Movie). Although no specific therapy was undertaken, the echocardiogram revealed completely recovered LV wall motion after 30 days, with no cardiac complications. The RV pacing rate was 100% throughout the pre- and postoperative periods.

Figure.

Radiographic images before (A) and after (B) additional lead insertion (arrowheads). Although pacing rhythm was only observed on electrocardiography (C), echocardiography revealed akinesis around the apical lesion. Coronary computed tomography also demonstrated no significant coronary artery stenosis (D), with apical akinesia and hypercontractile (arrowheads) basal segments (E–H). LV, left ventricle.

This is the first report of Takotsubo syndrome (TTS) due to additional RV lead insertion in a pacemaker user, clearly depicted by CCT. The accurate mechanisms triggering TTS are unknown; an emotional trigger is a possible cause.¹ Some cases of TTS occurring after mechanical manipulation of the myocardium, such as an ablation for atrial fibrillation, and after transcatheter mitral valve repair have been reported recently.^2,3 An improved understanding of detailed clinical characteristics and the pathophysiology of procedure-related TTS is required.

Disclosures

K.N. is a member of Circulation Reports’ Editorial Team. All authors declare no competing interests related to this work.

IRB Information

Not applicable.

Supplementary Files

Supplementary Movie

Please find supplementary file(s);

http://dx.doi.org/10.1253/circrep.CR-22-0073

References

• 1.   Yoneyama K, Akashi YJ. Myocardial contractile function recovery, systemic inflammation, and prognosis in Takotsubo syndrome. Circ J 2021; 85: 1832–1833.
• 2.   Miyahara K, Miyazaki S, Tada H. Silent Takotsubo cardiomyopathy after cryoballoon ablation. Europace 2019; 21: 1662.
• 3.   Kadosaka T, Kamiya K, Nagai T, Anzai T. Takotsubo syndrome after transcatheter mitral valve repair. Circ J 2021; 85: 1100.