Takotsubo Syndrome after Pacemaker Implantation: A Systematic Review

Abstract

Background: Takotsubo syndrome (TTS) is an acute cardiac condition characterized by a temporary wall motion abnormality of the left ventricle that mimics an acute coronary syndrome (ACS). TTS usually occurs following emotional or physical triggering event. More recently, sporadic cases of TTS arising after pacemaker implantation were reported. Methods: We performed a systematic review of the available literature to provide a comprehensive overview of the current knowledge about pacemaker implantation-induced TTS. Results: The articles selected included case reports and one registry on 28 patients. Most cases occurred in women (75%), encompassing a broad age range. The mean age of the cases described was 74 years. Full recovery of cardiac function was reported in most cases (92.3%), with largely varying recovery times, on average 7 weeks. The most common comorbidity was arterial hypertension and the average ejection fraction at admission was approximately 62%. Clinical severity ranges from asymptomatic cases to severe clinical heart failure syndrome. Altogether the case fatality rate was 3.6%. Conclusions: For rare it might be, awareness about the potential to develop TTS after pacemaker implantation should prompt careful clinical monitoring, with daily electrocardiogram (ECG) monitoring and at least one echocardiographic examination prior to patients' discharge to allow early diagnosis and minimize the clinical risk.

Takotsubo Syndrome After Pacemaker Implantation: A Case Report and Literature Review

“…Most of the devices (23/28) were dual-chamber pacemakers. It is interesting to note that male patients totaled 25% (n = 7) in the study by Strangio et al 2 compared to 9%–10% in the unselected TTS population. 1 ECG changes were recorded in almost all cases, except for a few patients in whom ventricular pacing masked ST-segment abnormalities.…”

“…Since then, several other cases have been reported. Recently, Strangio et al 2 performed a systematic review of the literature in 2022. In their paper, they selected studies that fulfilled predefined inclusion criteria, including occurrence shortly after pacemaker implantation, the presence of apical ballooning, and no obstructive coronary artery disease, with other causes ruled out or considered unlikely.…”

“…Absent or incomplete recovery of LV function was observed in 8% of patients and could have been the result of either follow-up performed too early or an additional potential harmful effect of RV pacing, as suggested by the fact that the majority of asymptomatic patients had been implanted for SSS (where ventricular pacing is usually avoided), but, unfortunately, the percentage of ventricular pacing was not reported. 2 …”

“…We performed an additional literature search and found 13 more case reports that were not included in the systematic review by Strangio et al, 2 probably because they did not fulfill the criteria for inclusion. These reports described 13 patients with TTS following pacemaker implantation for AV block (38% men); the correlation between implantation and TTS was less clear because there were other confounding factors, such as the use of isoproterenol before the procedure, concomitant lead extraction, and complications occurring during or shortly after the procedure (ie, pneumothorax, lead dislodgment).…”

“…Pacemaker implantation has been described as a potential trigger for TTS, and its prevalence is not so rare and likely underestimated, also considering that about 20% of patients are mildly or entirely asymptomatic. 2 The clinical picture in this setting shows some peculiarities, and it is still unclear whether pathophysiologic mechanisms are somehow different compared to other forms of TTS and whether the acute initiation of right ventricular (RV) pacing is a possible trigger. In this article, after providing a description of a case that occurred in our center, we review and discuss currently available knowledge about this diagnosis, which is worthy of consideration in clinical practice.…”