Takotsubo Syndrome Complicated by Dynamic Left Ventricular Outflow Tract Obstruction After Left Bundle Branch Area Pacing

Figures

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  Figure 1. Admission electrocardiogram. Second-degree atrioventricular block with 2:1 conduction and complete right bundle branch block.

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  Figure 2. Postimplant electrocardiogram. Electrocardiogram obtained 2 hours after pacemaker implantation, at the onset of dyspnea, demonstrating ST-segment elevations in leads V4–V6. Leads V1–V3 are not visible owing to a compressive bandage.

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  Figure 3. Chest radiography. Evidence of pulmonary venous congestion. D = right side.

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  Figure 4. Postimplant transthoracic echocardiogram. A: Apical 4-chamber view in diastole showing the Biotronik Solia S 60 pacing lead positioned in the basal interventricular septum (blue arrow). B: Apical 4-chamber view in systole demonstrating hypokinesia of the apical and para-apical segments (yellow arrows), apical ballooning, and basal hyperkinesia. Systolic anterior motion of the anterior mitral leaflet is also evident (red arrow). C: Color Doppler imaging from the apical view showing systolic flow acceleration through the left ventricular outflow tract (LVOT). D: Continuous-wave Doppler revealing dynamic LVOT obstruction.

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  Figure 5. Coronary angiography and ventriculography. A: Patent left and right coronary arteries. B: Left ventriculogram showing apical ballooning with preserved basal contractility, consistent with Takotsubo syndrome.

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  Figure 6. Follow-up electrocardiogram. Electrocardiogram recorded on day 3 (1 day after implant) showing resolution of ST-segment elevations with new-onset diffuse T-wave inversions in the anterior leads.

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  Figure 7. Electrocardiogram at discharge. Electrocardiogram on day 13 (before discharge) demonstrating improved paced QRS morphology and less pronounced T-wave inversions in the precordial leads compared with earlier follow-up. A significant reduction in peak left ventricular activation time was also noted.

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  Figure 8. Electrocardiogram at 1-month follow-up. Electrocardiogram obtained at the 1-month follow-up. The output configuration was switched from bipolar to unipolar to optimize the 12-lead surface morphology. The tracing demonstrates complete normalization of ventricular depolarization during paced rhythm.