The Egyptian Heart Journal Pub Date : 2021-06-26 , DOI: 10.1186/s43044-021-00182-5 John E Madias 1, 2
To the Editor:
I enjoyed very much reading the article by Revilla-Martí et al. [1], describing a 61-year-old man who suffered takotsubo syndrome (TTS) associated with transient high-grade atrioventricular (AV) block (HGAVB). The patient’s initial blood pressure of 90/60 is in keeping with early vagotonia seen in some patients in the setting of TTS [2, 3]; I wonder what was the heart rate (HR) of the patient’s sinus activity, which if slow would further support this attribution. The authors appropriately did not proceed with a pacemaker implantation, since the HGAVB was transient, with resolution prior to restoration of normal left ventricular function. I have some questions for the authors: (1) The QRS complexes in Fig. 1 appear wide (what was their width?), did they narrow in subsequent electrocardiograms (ECG) in the hospital and at follow-up? (2) Narrower subsequent QRS complexes would be supportive of the notion that the transient block was primarily at the His bundle level in addition to (or alternatively in the absence of) some impairment of the AV conduction, supported by the persisting long P-R interval at follow-up. (3) Were the QRS complexes narrower in a possibly available previous ECG, than the ones in the ECG of Fig. 1? (4) What were the HRs in such ECGs? (5) This will provide an explanation for the issue raised by the authors regarding the underlying pathophysiology (i.e., “supposed magnified sympathetic tone” and “ the apex” being “far away from the AV node, is the location of the most common wall segment motion abnormality” [1]), in the sense that the AV block was primarily or even exclusively related to transient intra-Hissian injury, engendered by the TTS-related tissue changes closer to areas of ventricular dyskinesis, rather than the remotely located AV node. (6) Was the P-R interval longer in the hospital than in subsequent ECGs at follow-up? (7) What were the HRs, P-R intervals, and QRS complex width in ECGs during hospital stay, discharge, and follow-up? (8) Are there any ECGs prior to the admission with TTS, showing a normal P-R interval and narrower QRS complexes than the ones seen in Fig. 1? (9) It is conceivable that diffuse spasm in small coronary branches could have caused ischemia in both the AV node and the Hiss bundle, or an increase in vagal tone could have affected the AV node. (10) TTS is associated with myocardial edema (ME), and one wonders about the effect of ME in the conduction velocity of the Hiss bundle, as a result of ME affecting it and/or the surrounding myocardium, wherein the Hiss bundle is embedded.
Not applicable.
- AV:
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Atrioventricular
- ECG:
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Electrocardiogram(s)
- HGAVB:
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High-grade AV block
- ME:
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Myocardial edema
- TTS:
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Takotsubo syndrome
- 1.
Revilla-Martí P, Cueva-Recalde JF, Linares-Vicente JA, Río-Sánchez S, Ruiz-Arroyo JR (2021) High-degree atrioventricular block. An unusual presentation of takotsubo cardiomyopathy: a case report. Egypt Heart J 73(1):18. https://doi.org/10.1186/s43044-021-00144-x.73:18
Article PubMed PubMed Central Google Scholar
- 2.
Samuels MA (2007) The brain–heart connection. Circulation 116(1):77–84. https://doi.org/10.1161/CIRCULATIONAHA.106.678995
Article PubMed Google Scholar
- 3.
Madias JE (2015) Plausible speculations on the pathophysiology of takotsubo syndrome. Int J Cardiol. 188:19–21. https://doi.org/10.1016/j.ijcard.2015.04.015
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Icahn School of Medicine at Mount Sinai, New York, NY, USA
John E. Madias
Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY, 11373, USA
John E. Madias
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Madias, J.E. Transient high-degree AV block in takotsubo syndrome. Egypt Heart J 73, 57 (2021). https://doi.org/10.1186/s43044-021-00182-5
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DOI: https://doi.org/10.1186/s43044-021-00182-5
中文翻译：
Takotsubo 综合征的一过性高度房室传导阻滞
致编辑：
我非常喜欢阅读 Revilla-Martí 等人的文章。[1]，描述了一名 61 岁男性，他患有与一过性高级别房室 (AV) 传导阻滞 (HGAVB) 相关的 takotsubo 综合征 (TTS)。患者的初始血压 90/60 与 TTS 环境中某些患者的早期迷走神经一致 [2, 3]；我想知道患者鼻窦活动的心率 (HR) 是多少，如果慢的话，这将进一步支持这种归因。作者没有适当地进行起搏器植入，因为 HGAVB 是短暂的，在恢复正常左心室功能之前已解决。我有一些问题要问作者：（1）图 1 中的 QRS 波群看起来很宽（它们的宽度是多少？），在随后的医院和随访心电图 (ECG) 中，它们是否变窄？(2) 较窄的后续 QRS 波群将支持以下观点，即暂时性传导阻滞主要在希氏束水平，此外（或在没有）AV 传导的一些损害，由持续的长 PR 间期支持跟进。(3) 在可能可用的先前心电图中的 QRS 波群是否比图 1 的心电图中的更窄？(4) 这些心电图中的 HR 是多少？(5) 这将为作者提出的有关潜在病理生理学的问题提供解释（即“假设放大的交感神经张力”和“心尖部”“远离房室结，是最常见壁的位置”段运动异常” [1]), 从某种意义上说，房室传导阻滞主要或什至完全与短暂的希氏内损伤有关，由更靠近心室运动障碍区域的 TTS 相关组织变化引起，而不是位于远处的房室结。(6) 住院期间的 PR 间期是否比后续 ECG 中的随访时间长？(7) 住院、出院和随访期间心电图的 HR、PR 间期和 QRS 波群宽度是多少？(8) 在 TTS 入院前是否有任何心电图，显示正常的 PR 间期和比图 1 中看到的更窄的 QRS 波群？(9) 可以想象，小冠状动脉分支的弥漫性痉挛可能导致 AV 结和 Hiss 束的缺血，或者迷走神经张力的增加可能影响了 AV 结。(10) TTS 与心肌水肿 (ME) 相关，
不适用。
- 影音：
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房室
- 心电图：
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心电图
- HGAVB：
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高档AV块
- 我：
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心肌水肿
- 话音：
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Takotsubo综合征
- 1.
Revilla-Martí P、Cueva-Recalde JF、Linares-Vicente JA、Río-Sánchez S、Ruiz-Arroyo JR (2021) 高度房室传导阻滞。Takotsubo 心肌病的不寻常表现：病例报告。埃及之心 J 73(1):18。https://doi.org/10.1186/s43044-021-00144-x.73:18
文章 PubMed PubMed Central Google Scholar
- 2.
Samuels MA (2007) 脑心连接。流通 116(1):77–84。https://doi.org/10.1161/CIRCULATIONAHA.106.678995
文章 PubMed Google Scholar
- 3.
Madias JE (2015) 对 takotsubo 综合征病理生理学的合理推测。国际心脏杂志。188:19-21。https://doi.org/10.1016/j.ijcard.2015.04.015
文章 PubMed Google Scholar
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Madias, JE takotsubo 综合征中的一过性高度房室传导阻滞。埃及之心 J 73, 57 (2021)。https://doi.org/10.1186/s43044-021-00182-5
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