Takotsubo Syndrome, Complete Heart Block, and Cardiac Arrest: A Clinical Challenge

Complete atrioventricular block may be associated with Takotsubo syndrome, and the decision of device implantation in such patients is challenging. We present a case of a 76-year-old woman admitted after out-of-hospital cardiac arrest that was reverted after defibrillation treatment. Post-resuscitation electrocardiogram documented complete atrioventricular block, and echocardiogram revealed severe left ventricular dysfunction with apical ballooning. Coronary angiography excluded coronary artery disease, and Takotsubo syndrome was diagnosed based on clinical and imaging features. Atrioventricular block persisted despite normalization of left ventricular function; therefore, cardiac arrest was considered secondary to a ventricular arrhythmia induced by atrioventricular block, and a pacemaker, rather than an implantable cardioverter-defibrillator, was implanted. During follow-up, complete atrioventricular block persisted, with 99% of ventricular pacing observed upon device interrogation. This case supports that the stress of atrioventricular block may trigger Takotsubo syndrome, which is reinforced by the persistence of conduction abnormalities despite reversal of ventricular defects. Therefore, early implantation of a cardiac device should be carefully considered on a case-by-case basis.