Delayed-Onset Life-Threatening Takotsubo Cardiomyopathy Following Pulsed-Field Ablation

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  Visual Summary. Serial Electrocardiographic and Imaging Findings After Pulsed-Field Ablation PFA achieved successful pulmonary vein, posterior wall, and superior vena cava isolation, as confirmed by the postablation electroanatomical voltage map (day 1). No significant electrocardiographic abnormalities were observed immediately after the procedure. Three hours later, the patient developed QT prolongation and high-degree atrioventricular block, which progressed to ventricular arrhythmia leading to cardiac arrest. Emergent coronary angiography showed no significant stenosis. Left ventriculography revealed apical ballooning with preserved basal contraction (arrowheads), consistent with Takotsubo cardiomyopathy (day 1). Deep T-wave inversions were observed in the precordial leads on day 2, with gradual normalization by day 68. AVB = atrioventricular block; PFA = pulsed-field ablation; PVI = pulmonary vein isolation; PWI = posterior wall isolation; SVC = superior vena cava.

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  Figure 1. Baseline Electrocardiographic and Procedural Findings Before the Acute Event (A) Twelve-lead electrocardiogram obtained before the procedure demonstrating atrial fibrillation without significant ST-segment or T-wave abnormalities. (B) Fluoroscopic image showing positioning of the pentaspline pulsed-field ablation catheter on the left atrial posterior wall during the procedure. (C) Three-dimensional electroanatomical map of the left atrium after ablation, demonstrating lesion distribution after pulmonary vein isolation and posterior wall isolation. Red areas indicate low bipolar voltage (<0.5 mV), whereas purple areas indicate preserved bipolar voltage (≥0.5 mV). (D) Postprocedural electrocardiogram in sinus rhythm showing no acute ischemic changes immediately after completion of the procedure

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  Figure 2. Clinical Presentation and Diagnostic Evaluation During the Acute Event (A) Continuous electrocardiographic monitoring demonstrating high-degree atrioventricular block and QT prolongation, subsequently progressing to torsades de pointes and refractory ventricular fibrillation with cardiac arrest. (B) Emergent coronary angiography showing no significant stenosis in the left coronary artery (Left) or right coronary artery (Right). (C) Left ventriculography during diastole (Left) and systole (Right), demonstrating apical ballooning with preserved basal contraction (arrowheads), consistent with Takotsubo cardiomyopathy.

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  Figure 3. Evolution of Electrocardiographic Changes Associated With Takotsubo Cardiomyopathy (A) Electrocardiogram obtained on day 2 demonstrating diffuse T-wave inversion with QT prolongation, predominantly in the precordial leads. (B) Follow-up electrocardiogram showing normalization of T-wave abnormalities and QT interval.