Case report: high-degree atrioventricular block associated with takotsubo cardiomyopathy: What is the right timing for pacemaker implantation?

Background: Takotsubo cardiomyopathy (TCM) is a transient left ventricular systolic dysfunction typically triggered by emotional or physical stress. High-degree atrioventricular (AV) block is a rare but significant complication of TCM. Its occurrence raises complex management questions, particularly regarding the appropriate timing for permanent pacemaker implantation given the possible reversible nature of both conditions. Case Summary: We report the case of a 65-year-old woman with diabetes who was admitted for syncope and found to have a complete AV block. Echocardiography and cardiac MRI showed apical akinesia and basal hyperkinesia, consistent with TCM. Coronary angiography revealed no obstructive coronary artery disease. Despite isoprenaline infusion and temporary pacing, the AV block persisted. A dual-chamber permanent pacemaker was implanted on day 6. By day 15, left ventricular ejection fraction had normalized, and at one-month follow-up, sinus rhythm had recovered, though a left bundle branch block persisted. Discussion: A comprehensive review of Pubmed database reported 22 cases of TCM associated with high-degree AV block. Among them, 31.8% of patients experienced AV conduction recovery, mostly younger individuals. However, most of them had persistent AV block beyond one month, justifying pacemaker implantation. Our findings suggest that while permanent pacing is often necessary, a short observation period may be appropriate in haemodynamically stable, younger patients. Given the absence of formal guidelines, individualized management is essential, and further research is needed to optimize therapeutic strategies for this uncommon association.