Takotsubo syndrome presenting with syncope and third-degree atrioventricular block requiring permanent pacemaker implantation

Takotsubo syndrome (TS) is an acute but transient heart failure syndrome and it is very uncommon for TS to present as syncope with complete atrioventricular (AV)block.In this report,we aimed to present a case of TS complicated by third-degree AV block presented to the emergency department with syncope and requiring permanent pacemaker implantation.A 53-year-old female admitted to our emergency department with complaints of syncopal episodes and chest pain.Due to ongoing chest pain,electrocardiography (ECG) findings and segmentary wall motion abnormality on the transthoracic echocardiography (TTE),she was immediately transferred to cardiac catheterization laboratory.Coronary angiogram revealed normal coronary arteries and left ventriculography demonstrated apical ballooning and hypokinesis of the apex.As the diagnosis of TS was established,patient was transferred to coronary intensive care unit(CICU).Initial ECG at CICU demonstrated complete AV block with a heart rate of 35 beats/min.On third day of hospitalization,repeat TTE showed improved left ventricular functions with an ejection fraction of 50%.During the follow-up period in CICU,complete AV block persisted and the rhythm did not return to normal sinus rhythm after 6 days of monitorization.An electrophysiologic study demonstrated supra-hisian atrioventricular block and atrioventricular dissociation.On seventh day of hospitalization,TTE demonstrated recovered ventricular functions with an ejection fraction of 65% and a dual pacemaker was then implanted.Her third month follow-up was uneventful and TTE showed normal left ventricular functions but pacemaker interrogation revealed 99% of ventricular pacing.This case report demonstrated that,the decision to implant a permanent pacemaker on such patients should be considered on a case-by-case basis,and electrophysiologic study could be valuable on this decision.