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To the Editor— How to manage patients with Takotsubo cardiomyopathy and a previous pacemaker implantation?
LETTERS TO THE EDITOR To the Editor— How to manage patients with Takotsubo cardiomyopathy and a previous pacemaker implantation? We read with great interest the article by Stiermaier et al1 published in this journal that evaluated the prevalence of arrhythmias in a multicenter registry of 286 patients with Takotsubo cardiomyopathy (TTC). Regarding bradyarrhythmias, 3% presented with complete atrioventricular block and 7 patients underwent pacemaker implantation. Moreover, 13 patients (4.5%) at the time of admission had a preexisting pacemaker. Although we cannot ascertain whether bradyarrhythmias may trigger TTC,2 we agree with the authors that pacemaker implantation is reasonable if complete atrioventricular block is still present 1 week after admission for TTC. However, special attention is also required for those patients with previous pacemaker implantation during the acute and subacute phase of TTC. Indeed during both phases, increased ventricular pacing threshold can be found.3 Myocardial edema, a common feature of TTC, could transiently influence pacing threshold, increasing local tissue impedance, particularly with bipolar pacing. Therefore, this possibility should not be neglected and the experience of Stiermaier et al would be of great interest. In our clinical practice, transient increased pacing threshold, slight reduction in right ventricular (RV) sensing, and RV lead impedance can be found. Management mainly consists
1547-5271/$-see front matter B 2016 Heart Rhythm Society. All rights reserved.
in transiently increasing RV pacing output; it has to be individualized for each patient, however. Device interrogation during TTC hospitalization and at short-term follow-up (4 weeks) can be easily performed and should be part of standard management in these patients. Francesco Santoro, MD*† [email protected] Nicola Tarantino, MD* Pier Luigi Pellegrino, MD, PhD* Matteo Di Biase, MD* Natale Daniele Brunetti, MD, PhD* *
Cardiology Department University of Foggia Foggia, Italy † Asklepios Klinik – St. Georg Hamburg, Germany
References 1. Stiermaier T, Rommel KP, Eitel C, Möller C, Graf T, Desch S, Thiele H, Eitel I. Management of arrhythmias in patients with Takotsubo cardiomyopathy: is the implantation of permanent devices necessary? [published online ahead of print June 11, 2016]. Heart Rhythm. 〈http://dx.doi.org/10.1016/j.hrthm.2016.06.013〉. 2. Santoro F, Ieva R, Ferraretti A, Carpagnano G, Lodispoto M, De Gennaro L, Di Biase M, Brunetti ND. Acute renal failure, digoxin toxicity and brady-arrhythmia as possible triggers in Tako-Tsubo cardiomyopathy. Int J Cardiol 2013;165: e51–e52. 3. Chikata A, Omi W, Saeki T, Nagai H, Sakagami S. Repeated pacemaker dysfunction in a patient with recurrent takotsubo cardiomyopathy precipitated by hyponatremia. Int J Card 2014;170:443–444.
http://dx.doi.org/10.1016/j.hrthm.2016.07.028
1547-5271/$-see front matter B 2016 Heart Rhythm Society. All rights reserved.
in transiently increasing RV pacing output; it has to be individualized for each patient, however. Device interrogation during TTC hospitalization and at short-term follow-up (4 weeks) can be easily performed and should be part of standard management in these patients. Francesco Santoro, MD*† [email protected] Nicola Tarantino, MD* Pier Luigi Pellegrino, MD, PhD* Matteo Di Biase, MD* Natale Daniele Brunetti, MD, PhD* *
Cardiology Department University of Foggia Foggia, Italy † Asklepios Klinik – St. Georg Hamburg, Germany
References 1. Stiermaier T, Rommel KP, Eitel C, Möller C, Graf T, Desch S, Thiele H, Eitel I. Management of arrhythmias in patients with Takotsubo cardiomyopathy: is the implantation of permanent devices necessary? [published online ahead of print June 11, 2016]. Heart Rhythm. 〈http://dx.doi.org/10.1016/j.hrthm.2016.06.013〉. 2. Santoro F, Ieva R, Ferraretti A, Carpagnano G, Lodispoto M, De Gennaro L, Di Biase M, Brunetti ND. Acute renal failure, digoxin toxicity and brady-arrhythmia as possible triggers in Tako-Tsubo cardiomyopathy. Int J Cardiol 2013;165: e51–e52. 3. Chikata A, Omi W, Saeki T, Nagai H, Sakagami S. Repeated pacemaker dysfunction in a patient with recurrent takotsubo cardiomyopathy precipitated by hyponatremia. Int J Card 2014;170:443–444.
http://dx.doi.org/10.1016/j.hrthm.2016.07.028