Delayed ventricular pacing failure and correlations between pacing thresholds, left ventricular ejection fraction, and QTc values in a male with Takotsubo cardiomyopathy

Abstract

Background Transient pacing failure caused by transient increased pacing threshold has been reported in patients with transient left ventricular apical dysfunction (Takotsubo cardiomyopathy [TC]). Normal pacing thresholds usually recover after normalization of systolic dysfunction. Hypothesis Pacing failure correlates with clinics of TC. Methods We report the case of a 76‐year‐old man with a dual chamber pacemaker, admitted for acute chest pain and dyspnea and final diagnosis of TC. One month after index admission, the patient came back complaining again of chest pain. Unexpectedly, admission electrocardiogram showed ventricular pacing failure and an increased pacing threshold. In the following weeks, pacing threshold gradually recovered with left ventricular ejection fraction and QTc values. Results Ventricular pacing threshold correlated directly to QTc values and inversely to left ventricular ejection fraction over time (P < 0.05). Conclusions This is one of the first cases of delayed transient ventricular pacing failure in a male patient with transient left ventricular apical ballooning, in the presence of spared right ventricular function. Given the possibility of acute transient anomalies in myocardial impedance and pacing failure even in the subacute phase of TC several weeks after clinical onset of transient systolic dysfunction, pacing threshold should be carefully monitored in subjects with TC, both during the acute phase of the disease and in first months of follow‐up after discharge. Ventricular pacing threshold correlated directly to QTc values and inversely to left ventricular ejection fraction over time.

Takotsubo Syndrome after Pacemaker Implantation: A Systematic Review

“…This hypothesis seems to be supported by the significant correlation between corrected QT interval (QTc) an indirect sign of myocardial oedema, and ventricular pacing thresholds. However, Brunetti et al [36] reported a case of delayed transient ventricular pacing failure in a patient with TTS discharged after partial recovery of LV function, who was referred after 4 weeks with pacing failure, due to a concomitant increase in pacing threshold, subsequently returned within normal ranges after complete LV function recovery. In the case described by Brunetti et al [36] report probably, delayed evidence of pacing failure may coincide with further delayed QT prolongation, which usually peaks in the subacute phase of TTS rather than in the acute phase [37].…”

“…However, Brunetti et al [36] reported a case of delayed transient ventricular pacing failure in a patient with TTS discharged after partial recovery of LV function, who was referred after 4 weeks with pacing failure, due to a concomitant increase in pacing threshold, subsequently returned within normal ranges after complete LV function recovery. In the case described by Brunetti et al [36] report probably, delayed evidence of pacing failure may coincide with further delayed QT prolongation, which usually peaks in the subacute phase of TTS rather than in the acute phase [37]. Alternatively, it is possible that other conditions beyond QTc prolongation may have influenced ventricular pacing threshold and QT length.…”

Exploring the EVolution in PrognOstic CapabiLity of MUltisequence Cardiac MagneTIc ResOnance in PatieNts Affected by Takotsubo Cardiomyopathy Based on Machine Learning Analysis

“…Similarly, various studies suggested a significant prognostic value of parametric edema quantification (assessed by T1 and T2 mapping) and diffuse interstitial fibrosis (assessed by T1 mapping) 5,26–28 . Feature tracking CMR of all 4 cardiac chambers has also been shown to provide important information regarding risk stratification 29–32 .…”

Mechanical stress concealed force enhancement and ionic transient membrane potential and metabolism in akinesia of stress cardiomyopathy

“…Abnormalities in ECGs were shown in most Takotsubo patients and were associated with ST segment abnormalities [7, 9a, 9b, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25,26 27, 28] , prolonged QT intervals [29,30,31,32,33,34,35] , tachyarrhythmias [36] , and more extensive repolarization [16,37] . Prolonged QTc intervals during a Takotsubo episode is associated with a high risk of cardiovascular rehospitalization were reported [38] .…”

“…The significantly prolonged precordial T wave is altered by the spatial dispersion of ventricular repolarization [36] , which may be associated with ST segment elevation [30,19] and probable with ST depression in aVR and chest-led PR [36] . In mechanically lengthening cardiac muscle fibers, the cellular membrane depolarizes in a specific pattern, which significantly lasts the decay period of the repolization phase (Figure 2) [40] ; however, the action potential conduction velocity does not significantly change [41] . In a beta-receptor activation mimicking study, Takotsubo cardiomyocyte depolarization velocity was slowed down, and an enhanced late membrane influx current (INa) suppressed the efflux current (Ito), thus prolonging the action potential duration [42] , which is the basis of QT interval prolongation [43] .…”