Hello Mr XXXXXXX
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

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Dear,

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

Regards
Dr RS Varma

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