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Table of Contents
Year : 2021  |  Volume : 11  |  Issue : 1  |  Page : 24-28

Takotsubo cardiomyopathy and new-onset right bundle branch block in uncomplicated right ventricle pacing: Cause or coincidence?

1 Department of Cardiology, JSS Medical College Hospital, JSSAHER, Mysore, Karnataka, India
2 Deparment of Cardiology, Care Hospitals, Hitech City, Hyderabad, Telangana, India

Date of Submission29-Apr-2020
Date of Decision16-Jun-2020
Date of Acceptance23-Jun-2020
Date of Web Publication18-Feb-2021

Correspondence Address:
Dr. Manjappa Mahadevappa
Department of Cardiology, JSS Medical College Hospital, JSSAHER, Mysuru - 570 004, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/JICC.JICC_26_20

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Normally in the right ventricular (RV) paced rhythm, the electrocardiogram pattern will be of left bundle branch block (LBBB) pattern. A small percentage of patients can have right bundle branch block (RBBB) pattern in uncomplicated RV pacing. We are reporting here a rare occurrence of a new-onset RBBB in an RV paced patient which was coinciding with the onset of takotsubo cardiomyopathy following pulse generator re-implantation procedure.

Keywords: Left bundle branch block in right ventricle pacing, right bundle branch block in right ventricle pacing, stress cardiomyopathy, takotsubo cardiomyopathy

How to cite this article:
Mahadevappa M, Kulkarni P, Poornima K S, Guruprasad B V. Takotsubo cardiomyopathy and new-onset right bundle branch block in uncomplicated right ventricle pacing: Cause or coincidence?. J Indian coll cardiol 2021;11:24-8

How to cite this URL:
Mahadevappa M, Kulkarni P, Poornima K S, Guruprasad B V. Takotsubo cardiomyopathy and new-onset right bundle branch block in uncomplicated right ventricle pacing: Cause or coincidence?. J Indian coll cardiol [serial online] 2021 [cited 2021 Jun 13];11:24-8. Available from:

  Introduction Top

Takotsubo (octopus fishing pot) cardiomyopathy (TCM) was first described in Japan in 1990 by Sato et al. is also known as stress cardiomyopathy or broken heart syndrome or apical ballooning syndrome.[1],[2] It is an acute cardiac condition characterized by transient systolic dysfunction of the left ventricular (LV) apex and mid-ventricle with depressed LV function mimicking acute coronary syndrome (ACS) and recovers within few weeks.[3]

Normally in the right ventricle (RV) paced rhythm, the surface electrocardiogram (ECG) shows a left bundle branch block (LBBB) pattern. However, a small percentage of true RV paced patients can have the right bundle branch block (RBBB) pattern. Other causes for RBBB pattern include perforation of the RV septal or free wall, inadvertent positioning of the ventricular lead in the coronary sinus or the left ventricle, rarely intracardiac defects such as patent foramen ovale or a ventricular septal defect.[4],[5],[6] Hence, the occurrence of RBBB in RV paced patients needs thorough evaluation even if asymptomatic. In literature, the prevalence of RBBB in uncomplicated RV pacing is around 15.5'. Its occurrence is more common with RV apical pacing (27.5') when compared to mid septal pacing (1.9'), although varies between different studies.[7]

We are reporting here a rare case of TCM with new-onset RBBB in RV paced patient following a pulse generator (PG) re-implantation procedure for lead-induced skin erosion.

  Case Report Top

A 61-year-old female, post permanent pacemaker implantation (PPI) in 2018, presented with mild pain and discoloration of skin at the implant site for 2 weeks. No fever, giddiness, or pus at the site of the implant.

Local examination revealed possible lead-induced skin erosion [Figure 1] without any signs of infection. Vital parameters: pulse - 70 beats per minute (bpm), blood pressure - 130/80 mmHg, and peripheral capillary oxygen saturation of 98'. Systemic examination was unremarkable. The patient had no other comorbidities. A coronary angiogram (CAG) in 2018 showed normal coronaries. A provisional diagnosis of pacemaker PG/lead-induced skin erosion was made.
Figure 1: (a) Pre-procedure image showing imminent skin erosion due to protruding lead. (b) 3 days post-procedure after re-implantation of the pulse generator showing a new pulse generator implant site suture line and repaired skin erosion.

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Routine blood counts, renal function tests, liver function tests, and random blood sugars were within normal limits. ECG showed a paced rhythm with “a” sense and “v” pace at the rate of 70 bpm [Figure 2]. Two-dimensional echocardiogram (2D ECHO) showed normal chamber dimensions, no regional wall motion abnormalities (RWMA), normal LV systolic function, with mild pulmonary hypertension (RV systolic pressure 32 mmHg).
Figure 2: (a) Pre-pulse generator re-implant procedure ECG showing normal paced left bundle branch block pattern in V1, V2 and limb lead I. (b) Immediate post-pulse generator re-implant procedure ECG showing new-onset RBBB in V1 and V2. There is persisting LBBB pattern in the lead I and transition from RBBB to LBBB occurring in lead V3. (c) Changing V1 and V2 to the 5th intercostal space changes RBBB to LBBB pattern suggesting physiological right ventricular, mostly apical pacing. Lead I continue to record LBBB pattern

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Heart team discussion was done and decided to do surgical exploration and re-implantation of PG because of possible adhesions and procedural difficulty under general anesthesia. The permanent pacemaker (PPM) was evaluated and mode changed to VOO and underwent uneventful exploration and re-implantation of PG. However, postprocedure after extubation patient developed pulmonary edema and desaturated, hence, reintubated. ECG showed new-onset RBBB [Figure 2]b. A repeat 2D ECHO showed severely hypokinetic apical segments with preserved contractility of basal segments, apical ballooning of LV, no pericardial effusion, and interventricular septum was intact. LV ejection fraction was 30' [Figure 3]. Cardiac biomarkers were elevated. CXR showed pulmonary congestion with no displacement of RA or RV lead [Figure 4]. The patient was started on ACS protocol, diuretics, intravenous heparin, inotropes, antibiotics, and other symptomatic medications. Fluoroscopy revealed no dislodgment of RV and RA leads [Figure 5]. CAG showed normal coronaries. The pacemaker was re-evaluated with no change in parameters and mode reversed to DDD [Table 1]. The next day, the patient became hemodynamically stable and was extubated. ECHO revealed a marginal increase in LV function (EF = 35'). A diagnosis of stress cardiomyopathy or TCM was made. On the 4th day, the patient was discharged with guideline-directed medical therapy for heart failure and advised follow-up after 2 weeks. On follow-up, the patient was asymptomatic, ECHO showed complete recovery of LV function (EF=60') with the disappearance of RWMA and apical ballooning [Figure 6]. Conventional ECG continued to be of RBBB pattern with consistent pacing. However, ECG recorded with V1 and V2 in the 5th intercostal space revealed an LBBB pattern [Figure 2]c.
Figure 3: Labeled postprocedure echocardiogram images showing features of regional wall motion abnormalities involving mid and apical regions with apical ballooning and severely depressed left ventricular function-features suggestive of takotsubo cardiomyopathy in (a) apical 4 chamber (A4C) view. (b) apical 3 chamber (A3C) view and (c) parasternal short axis (PSAX) view.

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Figure 4: (a) Labeled image of chest X-ray posteroanterior view (pre pulse generator re-implant procedure) showing an intact right atrium and right ventricular leads with positions. Note pulse generator implant site. (b) Labeled images of chest X-ray posteroanterior view postprocedure showing pulse generator site and intact right atrium and right ventricular leads. Note features of pulmonary congestion-red arrow.

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Table 1: Pace maker parameters pre-surgery and postsurgery

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Figure 5: Labeled fluoroscopic images showing an intact right atrium and right ventricular leads in position. (a) RAO 34-Caudal 2 degrees view. (b) LAO 52 and Caudal 2 degrees view.

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Figure 6: Two weeks after the procedure, echocardiogram images showing recovered left ventricular function and disappearance of features of regional wall motion abnormalities and apical ballooning in (a) apical 4 chamber view. (b) apical 3 chamber view and. (c) parasternal short axis view

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  Discussion Top

Stress cardiomyopathy or TCM commonly affects postmenopausal women with intense physical or emotional stress[2],[3],[8] and has a favorable prognosis. TCM occurring during acute illnesses or during a procedure is well documented. The condition is diagnosed based on the modified Mayo Clinic[9] criteria which include transient RWMA, ECG changes or positive cardiac biomarkers, no angiographic evidence of coronary artery disease (CAD) or spasm, and absence of myocarditis or pheochromocytoma.[9] Potential ECG findings of TCM include ST-elevation, ST depression, new-onset LBBB, or prolonged QT interval.[1],[10],[11] However, these ECG changes are explained in patients with native rhythm. The kind of ECG changes TCM imparts in patients who already are paced by a device is not clear in the literature. In our case, the patient developed TCM during the PG re-implantation procedure which led to failed extubation and pulmonary edema after the procedure. Further evaluation revealed new-onset RBBB and TCM. We are not clear whether the new-onset RBBB was triggered by TCM or was independent of it. As the patient continues to have RBBB even after complete recovery from TCM implies that RBBB could be independent.

Several ECG features have been reported to predict an uncomplicated RV apical pacing when the paced QRS frontal axis is 0°–90° and precordial transition by V3 separates uncomplicated RV septal or apical pacing from all other forms of LV pacing.[12] The same frontal axis of 0°–90°, but precordial transition after V4 indicates pacing in the middle cardiac vein or posterior and posterolateral wall of the left ventricle. Frontal axes between -90° and -180° or between 90° and 180° indicate other locations of LV pacing.[12] Another way to map RV pacing is by recording V1 and V2 in the fifth intercostal space.[13] In the present case too, the transition happened from V3 onward, and changing V1-V2 to the 5th intercostal space changed RBBB to LBBB pattern.

Many reasons have been postulated for the RBBB pattern in RV pacing. Mower et al. suggested that there could be portions of interventricular septum which could be anatomical RV but functionally and electrically behave as LV. They also suggested that a pacemaker stimulus may enter the RBB and can travel in a retrograde direction to the AV junction and down the LBB.[14] Another postulate from them was if the screw tip is deeper into the septal plane then it could activate LV early.[14] However, Barold et al. stated that the combination of RV activation delay due to severe disease of the RV conduction system and early penetration of electrical impulse into the LV system could be responsible for RBBB.[15] A study of 47 cases of pacemaker implantation by Masahiro et al., in 2005 concluded that the RBBB pattern observed during RV endocardial pacing usually represents safe RV pacing rather than perforation or malposition of pacing leads.[16]

In our case, careful analysis of ECG [Figure 2], pacing parameters [Table 1], chest X-ray posteroanterior view [Figure 4], 2D ECHO [Figure 3], and fluoroscopy [Figure 5] further proved the correct position of the lead and RBBB was in the setting of uncomplicated RV pacing. These simple noninvasive tests should be done before subjecting the patient to any intervention.

Learning points from this case

  1. The exact reason for new-onset RBBB in uncomplicated RV pacing after 22 months of initial PPM procedure is not clear
  2. Proposed hypotheses are: (a) possible inadvertent pulling or pushing exerted on the lead during re-implantation and (b) simultaneous onset of TCM. However, as RBBB persisted even after complete recovery from TCM, it's difficult to ascertain the role of TCM in its causation. To know the impact of TCM on BBB pattern in paced patients, more studies are required in this rare subset of patients
  3. This case report should serve to sensitize the clinician about the possibility of RBBB in paced patients with the occurrence of TCM.

  Conclusion Top

The dramatic change in the ECG pattern from LBBB to RBBB in an RV paced patient can portend uncomplicated RV pacing to catastrophic complications. Prompt attention and meticulous evaluation to rule out lead perforation/dislodgement are extremely crucial in preventing morbidity and mortality. Although the RBBB pattern in uncomplicated RV pacing is seen in a minor percentage of patients, the exact mechanism is not known. This dramatic change when coupled with stress cardiomyopathy, as documented in our case can complicate management, and treating clinicians should be aware of this presentation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Sato H, Tateishi H, Uchida T, et al. Takotsubo type cardiomyopathydue to multivessel spasm. In: Kodama K, Haze K, Hon M, eds.Clinical aspect of myocardial injury: from ischemia to heart failure,Kagaku Hyoronsha, Tokyo, 1990, pp. 56–64   Back to cited text no. 1
Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: A systematic review. Europ Heart J 2006;27:1523-9.  Back to cited text no. 2
Prasad A. Apical ballooning syndrome: An important differential diagnosis of acute myocardial infarction. Circulation 2007;115:e56-9.  Back to cited text no. 3
Erdogan O, Altun A. Evaluation of intermittent capture in a patient who has undergone an urgent temporary transvenous pacemaker lead insertion. Postgrad Med J 2004;80:431-3.  Back to cited text no. 4
Altun A, Akdemir O, Erdogan O, Aslan O, Ozbay G. Left ventricular permanent lead insertion through the foramen ovale. A case reports. Angiology 2002;53:609-11.  Back to cited text no. 5
Mazzetti H, Dussaut A, Tentori C, Dussaut E, Lazzari JO. Transarterial permanent pacing of the left ventricle. Pacing Clin Electrophysiol 1990;13:588-92.  Back to cited text no. 6
Tzeis S, Andrikopoulos G, Weigand S, Grebmer C, Semmler V, Brkic A, et al. Right bundle branch block-like pattern during uncomplicated right ventricular pacing and the effect of pacing site. Am J Cardiol 2016;117:935-9.  Back to cited text no. 7
Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-48.  Back to cited text no. 8
Kawai S, Kitabatake A, Tomoike H, Takotsubo Cardiomyopathy Group. Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy. Circ J 2007;71:990-2.  Back to cited text no. 9
Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Koike H, Sasaka K. The clinical features of takotsubo cardiomyopathy. QJM 2003;96:563-73.  Back to cited text no. 10
Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, et al. Systematic review: Transient left ventricular apical ballooning: A syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004;141:858-65.  Back to cited text no. 11
Coman JA, Trohman RG. Incidence and electrocardiographic localization of safe right bundle branch block configuration during permanent ventricular pacing. Am J Cardiol 1995;76:781-4.  Back to cited text no. 12
Okmen E, Erdinler I, Oguz E, Akyol A, Turek O, et al. An electrocardiographic algorithm for determining the location of pacemaker electrode in patients with right bundle branch block configuration during permanent ventricular pacing. Angiology 2006;57:623-30.  Back to cited text no. 13
Mower MM, Aranaga CE, Tabatznik B. Unusual patterns of conduction produced by pacemaker stimuli. Am Heart J 1967;74:24-8.  Back to cited text no. 14
Barold SS, Narula OS, Javier RP, Linhart JW, Lister JW, et al. Significance of right bundle-branch block patterns during pervenous ventricular pacing. Br Heart J 1969;31:285-90.  Back to cited text no. 15
Masahiro O, Kazuhiko M, Takehiko N, Yoshinobu O, Yoshizumi K, Masayuki T, et al. Right bundle branch block like pattern recorded in right ventricular endocardial pacing. J Arrhythmia 2012;3:414-17.  Back to cited text no. 16


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]

  [Table 1]


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