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Undergone mitral valve repair, cardioversion, had a heart attack due to calcium channel blocker, high heartbeat. Pacemaker needed?

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Cardiologist, Interventional
Practicing since : 1996
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Is a pacemaker appropriate?
by joeyboy42, My wife had a mitral vakve repair 3 years ago as well as a maze to correct AF; heartbeat was in teh upper 90's so she then had a cardioversion to regularise heartbeat and this worked fine, bringing it down to the mid-60's. Earlier this year her specialist replaced her calcium channel blocker with an ARB. Shortly afterwards she experienced a heart attack; a subsequent ECG indicated a Taku-tsubo syndrome as well as Troponin positivity. She then had a Cardiac MRI scan which apparently revealed little, same for a 24 hour ECG despite her heartbeat going up to 140-160 on a number of days. It has been brought down with a Betablocker after two hospitals admissions through A & E.
Her heartbeat is currently in the higher 50's and lower 60's and a pacemaker is suggested to regularise the intermittent bradycardia and occasional tachycardia. Is this the appropriate treatment as there appears to be a lot of uncertainty regarding clinical decision-making?
Posted Wed, 2 May 2012 in Heart Rate and Rhythm Disorders
Answered by Dr. Raja Sekhar Varma 16 hours later
Thank you for your query.

As per the details given by you, your wife has had Mitral valve repair with a Maze procedure for atrial fibrillation, followed by cardioversion to maintain normal rhythm. She apparently has recently suffered from Tako-Tsubo syndrome.

Tako-Tsubo syndrome is a type of stress-related cardiomyopathy. It is not a true heart attack. The apex of the heart balloons out (possibly due to high sympathetic overload and the effect of other hormones due to stress). While the ECG, cardiac enzyme tests (like troponin) and echo can simulate the picture of an acute heart attack, a coronary angiogram will not show a lesion/thrombus. Most of the time, this apical ballooning is reversible with time, and the cardiac function improves over a period of weeks to months. Arrhythmias are known to occur during this period.

Before commenting on the need for a pacemaker, I would like to know some facts:
1) How many months has passed since the diagnosis of Tako-Tsubo syndrome?
2) Has the syndrome been confirmed by a coronary angiogram
3) What is the current status of the mitral valve?
4) What are the findings of the latest echocardiogram as regards to LV function?
5) Can you upload on this website the ECGs showing the arrhythmias, bradycardia or tachycardia?
6) Can you also upload the results of the Holter test (24 hour ECG recording)?

Kindly get back to me with the answers to these questions and the ECGs so that I can give you a specific reply as to the need for a pacemaker.

With regards,
Dr RS Varma
Above answer was peer-reviewed by
Follow-up: Undergone mitral valve repair, cardioversion, had a heart attack due to calcium channel blocker, high heartbeat. Pacemaker needed? 11 days later
First admission to A&E in XXXXXXX showed positive cardiac enzymes. 'Her coronary angiogram did not reveal significant pathology'. Suggested Taku-tsubo syndrome, cardiac MRI scan broadly suggested same. Second admission in July ECG showed new T-wave inversions and cardiac Trop was negative. Interpretation of echocardiogram 'was not suggestive of Takusubo syndrome'. 'Changes consistent with LAD infarct'
Third A&E discharge note Sept. 11, states ' admitted with SOB and tachycardia, found to be in AF, Troponion negative, bradycardia at times; proposed treatment OP PPM insertion to treat tachy/brady syndromea
Answered by Dr. Raja Sekhar Varma 6 hours later

1. The symptoms of chest pain with positive cardiac enzymes and normal coronary angiogram that happened during the first admission is consistent with the diagnosis of Tako-Tsubo syndrome. The second echo in July casts some doubt over this diagnosis. However, it might have been too early for the changes of Tako-Tsubo syndrome to revert.

You have not mentioned if a third echo was done subsequently this month. Another echocardiogram done now will probably tell us if the changes have completely reverted and the status of the left ventricular function. Discuss with your cardiologist and consider getting a third echo done.

2. The tachy-brady syndrome comes under the general diagnosis of "sinus node dysfunction", previously also referred to as "sick sinus syndrome".

A pacemaker is indicated if there is-
a) Significant bradycardia with symptoms due to the bradycardia like giddiness or transient loss of consciousness,
b) Significant sinus pauses causing symptoms,
c) If the awake heart rate is less than 30/minute in the absence of symptoms, or <40/minute in the symptomatic patient.

Sometimes this bradycardia may be due to necessary drug therapy for tachycardia, that cannot be stopped. In such cases, a pacemaker would help to prevent bradycardia, while higher and more effective doses of drugs can be given to tackle the tachycardia.

Also, there are certain types of pacemakers which can prevent atrial fibrillation or reduce the duration of atrial fibrillation by special types of pacing responses to atrial premature contractions that usually trigger AF.
Of course, if the patient is continually in AF, this will not work.

Pacemaker insertion can be considered if any of the options are associated with your condition. You may discuss about these with your primary cardiologist.

Hope this helps

Dr RS Varma
Above answer was peer-reviewed by
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