A 53-year-old woman presented in complete heart block after an episode of syncope. She was hanging out washing when a 5 m deep sinkhole opened up beneath her.
On arrival to our emergency department, the patient was lucid and asymptomatic. The clinical examination was unremarkable.
Twelve-lead electrocardiogram showed sinus rhythm with third-degree atrioventricular (AV) block and a junctional escape of 50 bpm (Panel A). Initial investigations were unremarkable.
Transthoracic echocardiogram demonstrated severely reduced left ventricular (LV) ejection fraction with akinesis of all mid-myocardial segments extending into adjacent basal and apical segments but sparing true apex and the very base (Panel B).
Three hundred and twenty-slice computed tomography coronary angiogram demonstrated no coronary atherosclerosis (Panel C), confirming the clinical suspicion that the patient's abnormal LV contraction represented a stress cardiomyopathy.
The patient remained in complete heart block with a stable junctional escape rhythm (40–50 bpm). Seven days post-admission, a repeat transthoracic echocardiogram demonstrated normalization of LV contraction (Panel D), yet complete heart block persisted. A dual-chamber permanent pacemaker was inserted.
There have been rare reports of high-degree AV block and takotsubo cardiomyopathy occurring together in medical literature. Occasionally, cardiomyopathy persists after improvement of left ventricular wall motion necessitating implantation of a permanent pacemaker.
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