Two Blocks and A Broken Heart: Takotsubo Syndrome with Complete Atrioventricular Block and Small Bowel Obstruction - A Case Report

Takotsubo syndrome (TTS), complete atrioventricular (AV) block, and acute extracardiac illness may coexist, obscuring their causal sequence. A 64-year-old woman presented with severe epigastric pain and vomiting, high-sensitivity troponin of 340 ng/L peaking at 1,581 ng/L, B-type natriuretic peptide of 540 pg/mL, and high-grade AV block progressing to complete block. Echocardiography showed circumferential mid-apical akinesis with basal hyperkinesis and a left ventricular ejection fraction (LVEF) of 30%, while urgent coronary angiography demonstrated normal epicardial coronary arteries. Persistent gastrointestinal symptoms prompted abdominal computed tomography, which identified acute small bowel obstruction with concern for early bowel compromise. Bowel transit resumed with conservative treatment. Cardiac magnetic resonance showed apical ballooning and myocardial edema without perfusion defect or late gadolinium enhancement, supporting TTS. Before permanent pacing, LVEF improved to 44%, but complete AV block persisted with an intrinsic ventricular rate of 35–38 beats/min; a dual-chamber pacemaker was subsequently implanted. Small bowel obstruction may have triggered TTS, whereas the AV block may have been a consequence, an additional trigger, or pre-existing conduction disease. The early dissociation between partial myocardial recovery and persistent AV block shows that electrical recovery cannot be inferred from LVEF improvement and that pacing decisions require independent assessment of conduction.