Simultaneous takotsubo cardiomyopathy with high av block during acute sarscov-2 viral infection: a rare complication of covid-19

Background: COVID-19 has been described to cause coronary thrombosis, heart failure, transient ST-segment elevation, and less commonly atrioventricular (AV) block. There are no documented cases upon extensive literature review of COVID-19 causing both Takotsubo cardiomyopathy (TCM) and high degree AV block. Case: 80 year old female with HTN and DNR code status presents with fatigue. Rapid COVID-19 testing was positive. Electrocardiogram revealed third degree AV block that did not improve with atropine and dopamine; therefore, a transvenous pacemaker (TVP) was placed. Heparin drip was initiated for a troponin-I of 3.25 ng/mL. Transthoracic echocardiogram with poor acoustic windows showed reduced ejection fraction of 25% and anterior and apical wall hypokinesis. Left heart catheterization (LHC) revealed non-obstructive coronary artery disease. Left ventriculogram revealed apical hypokinesis with anterior and inferior basal contraction, consistent with TCM. Reconduction of her system occurred and TVP was discontinued. However, telemetry noted intermittent bouts of complete AV dissociation. A dual-chamber permanent pacemaker was inserted. She was discharged on guideline directed medical therapy for heart failure with reduced ejection fraction. Decision - making: High degree AV block with significantly elevated troponin-I led