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 Table of Contents  
CASE REPORT
Year : 2018  |  Volume : 7  |  Issue : 3  |  Page : 115-117

A rare case of takotsubo cardiomyopathy: The masquerader


Department of Cardiology, AIIMS, Bhopal, Madhya Pradesh, India

Date of Web Publication10-Jul-2018

Correspondence Address:
Dr. Agam Bansal
Room No. 213, Boys Hostel, AIIMS, Bhopal - 462 020, Madhya Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JCPC.JCPC_6_18

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  Abstract 

Takotsubo cardiomyopathy (TCM) is a form of transient systolic dysfunction that masquerades myocardial infarction clinically. We report a case of a 57-year-old female with a normal cardiac profile who underwent an abdominal surgery. However, immediately after the operation, she developed chest pain and dyspnea, ST-segment elevation and QRS complex widening on electrocardiography, and increased left ventricle diastolic diameter, apical ballooning, and decreased ejection fraction on two-dimensional echocardiography. However, coronary angiography was normal. Based on these findings, she was diagnosed with TCM. She was started on diuretics and beta-blocker, and her heart function returned to normal within 2 weeks. Possibility of TCM should be kept in mind when acute coronary syndrome like manifestation is immediately preceded by a stress episode, like in this case.

Keywords: Apical ballooning syndrome, stress, takotsubo cardiomyopathy


How to cite this article:
Khandelwal G, Bansal A. A rare case of takotsubo cardiomyopathy: The masquerader. J Clin Prev Cardiol 2018;7:115-7

How to cite this URL:
Khandelwal G, Bansal A. A rare case of takotsubo cardiomyopathy: The masquerader. J Clin Prev Cardiol [serial online] 2018 [cited 2020 May 26];7:115-7. Available from: http://www.jcpconline.org/text.asp?2018/7/3/115/236333


  Introduction Top


Takotsubo cardiomyopathy (TCM) or stress-induced cardiomyopathy or apical ballooning syndrome is a form of transient systolic dysfunction that mimics myocardial infarction (MI) in terms of symptoms (chest pain and dyspnea), electrocardiography (ECG), and two-dimensional (2D) echocardiography findings but without any obstruction in coronary arteries.[1] The true prevalence of TCM is about 1%–2% of cases in individuals with clinical suspicion of acute coronary syndrome.[2]

We report a case of a 57-year-old female who was documented to have a normal cardiac status, and immediately, after her surgery for umbilical hernia, she developed findings suggestive of TCM. She was followed up to track the gradual changes to normalcy of her investigations. This unique case closely describes the cascade of clinical changes in the heart following TCM.


  Case Report Top


A 57-year-old female was admitted to our hospital for elective umbilical hernia operation. She was obese (weight 108 kg), hypertensive for 12 years, and diabetic for 10 years and was on treatment for these. Preoperatively, she had no history of angina or dyspnea on exertion. Her ECG and chest X-ray were normal. 2D echocardiography showed Grade I left ventricle (LV) diastolic dysfunction, with a normal LV systolic function and normal LV ejection fraction (55%). Hernia repair with Parietex mesh was planned. Rapid sequence induction was given with propofol and succinylcholine, followed by tracheal intubation. Anesthesia was maintained with oxygen: air 1:1 mixture, sevoflurane, and remifentanil. During the surgery, the patient had tachycardia and her systolic blood pressure dropped to 90s for which she was started on inotropes. After the operation, the patient became dyspneic and was shifted to Intensive Care Unit (ICU) and placed on mechanical ventilation. ECG in ICU was significant for sinus tachycardia and Q-waves with QRS widening and up coving ST segments on V1–V3 leads [Figure 1]. 2D echocardiography was significant for internal LV diastolic diameter of 59 mm [Figure 2], left ventricular apical ballooning and severely hypokinetic anterior territory-LV apex, mid-distal anterior septal, mid-distal anterior wall, and decreased LV ejection fraction of 25%. Cardiac enzymes (CPK-MB) were normal. The patient was started on i.v. inotropes and i.v. diuretics. After few hours, the patient had a coronary angiography which revealed normal coronary arteries [Figure 3]. On the next day, the patient improved clinically, and ECG showed Q-waves with coved up ST-segment elevation in V1–V4. Inotropes were tapered and beta-blocker was initiated. Echocardiography showed hypokinesia in the anterior territory with slightly improved LV ejection fraction of 35%. The patient was discharged 6 days after the operation, on medical treatment in stable condition. The patient followed up after 15 days' postoperation. She had New York Heart Association Class I dyspnea. ECG showed rS-wave in V1–V4 and deep T-wave inversion in all anterolateral leads. Echo showed normal chamber dimensions, no regional wall motion abnormalities, and normal LV ejection fraction of 55%.
Figure 1: Electrocardiography during distress

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Figure 2: Echocardiogram during the surgery day

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Figure 3: Coronary angiogram postoperative

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  Discussion Top


TCM is more common in postmenopausal women demonstrating > 80% female predominance with a mean age of 58–77 years and is precipitated by physical and emotional stress.[3] The patient closely followed this profile, and operative stress was the trigger. Stress may lead to adrenergic excess and stimulate brain–heart axis to cause coronary microcirculation vasoconstriction and consequent myocardial stunning, thus precipitating TCM.

The patient had all the findings of Mayo Clinic diagnostic criteria [4],[5] that characterizes TCM: (1) 2D echocardiography findings of LV apical ballooning, reversible wall motion abnormality (particularly hypokinesia in the left ventricular mid-segments), and transient systolic dysfunction (decrease in ejection fraction followed by return to normal within 15 days); (2) absence of any obstruction on coronary angiography; (3) appearance of new ECG abnormalities (Q-waves with QRS widening and ST elevation) postoperatively; and (4) absence of fever and viral prodrome, no systemic abnormalities suggestive of autoimmune disease, and no intake of drugs that could predispose to myocarditis. Her blood pressure was on lower side, and there are no palpitations or episodic headaches, thus eventually ruling out pheochromocytoma. Normal cardiac enzymes and normal coronary angiogram ruled out MI, which is the closest differential. As > 80% of patients with TCM have elevated troponin levels and nearly 80% have signs of myocardial ischemia on initial ECG, early coronary angiography remains necessary to rule out an acute coronary syndrome.[1] She had a normal LV with LV end-diastolic diameter of 42 mm before surgery, which ballooned up to become of 59 mm, and again returned back to normal of 37 mm, about 15 days after the event. Similarly, ECG went through a cascade of tachycardia, ST-segment elevation, QRS widening, and then finally, ST normalized and R-wave regained.

Our case highlights the possibility of TCM with the anesthetic agents such as propofol, succinylcholine, sevoflurane, and remifentanil. These agents have been only occasionally associated with TCM.[6],[7] This makes our case unique and worth reporting even though perioperative TCM has been reported in numerous case reports.

The prognosis of TCM is generally good, with resolution of systolic function within a few weeks.[8] Our patient had improvement in her symptoms clinically. Also ECG had normalized and echocardiography showed normal LV systolic function. She returned to normal status after 15 days. However, some individuals can develop potential life-threatening complications during the acute state including heart failure, ventricular tachycardia and fibrillation, bradyarrhythmias, thrombus formation and embolism, mitral regurgitation, and cardiogenic shock.[9],[10] Beta-blockers, diuretics, and angiotensin-converting enzyme inhibitors are the mainstay of treatment for TCM. Intravenous inotropes and intra-aortic balloon pump can be used in individuals having hypotension/shock associated with LV dysfunction.[10],[11] Anxiolytics and opioids can be added to decrease the stress response.

There are several measures that can be adopted to decrease the stress and hence chances of TCM during surgery. Efforts to relieve the anxiety preoperatively by means of psychological or pharmacological approach (with prophylactic beta-blockers) have shown decreased incidence of TCM.[10] Regional anesthesia with sedation can be preferred over general anesthesia whenever feasible because of decreased catecholamine release. Anesthetic agent with least myocardial depression should be preferred to decrease the risk of TCM. Brief laryngoscopy, smooth extubation, and adequate pain control are other measures to decrease the stress response to surgery.

It is important to monitor for symptoms of transient heart dysfunction in immediate postoperative period even in patients with normal cardiovascular status. Echocardiography is an indispensable tool for diagnosis of TCM. Early detection and adequate supportive management ensures a good prognosis and can prevent rare but life-threatening complications such as arrhythmias, heart failure, and cardiogenic shock.

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

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, et al. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. N Engl J Med 2015;373:929-38.  Back to cited text no. 1
    
2.
Komamura K, Fukui M, Iwasaku T, Hirotani S, Masuyama T. Takotsubo cardiomyopathy: Pathophysiology, diagnosis and treatment. World J Cardiol 2014;6:602-9.  Back to cited text no. 2
    
3.
Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E, et al. Apical ballooning syndrome or takotsubo cardiomyopathy: A systematic review. Eur Heart J 2006;27:1523-9.  Back to cited text no. 3
    
4.
Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-tsubo or stress cardiomyopathy): A mimic of acute myocardial infarction. Am Heart J 2008;155:408-17.  Back to cited text no. 4
    
5.
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. 5
    
6.
Cabaton J, Rondelet B, Gergele L, Besnard C, Piriou V. Tako-tsubo syndrome after anaphylaxis caused by succinylcholine during general anaesthesia. Ann Fr Anesth Reanim 2008;27:854-7.  Back to cited text no. 6
    
7.
Preti A, Ceddaha M, Christias M, Scemama M, Rouquette I. Takotsubo cardiomyopathy and anaesthesia. Br J Anaesth 2010;105:236-7.  Back to cited text no. 7
    
8.
Lee PH, Song JK, Sun BJ, Choi HO, Seo JS, Na JO, et al. Outcomes of patients with stress-induced cardiomyopathy diagnosed by echocardiography in a tertiary referral hospital. J Am Soc Echocardiogr Off Publ Am Soc Echocardiogr 2010;23:766-71.  Back to cited text no. 8
    
9.
Pilgrim TM, Wyss TR. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review. Int J Cardiol 2008;124:283-92.  Back to cited text no. 9
    
10.
Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, et al. Acute and reversible cardiomyopathy provoked by stress in women from the united states. Circulation 2005;111:472-9.  Back to cited text no. 10
    
11.
The use of Dopamine in Takotsubo Cardiomyopathy-International Journal of Cardiology. Available from: http://www.internationaljournalofcardiology.com/article/S0167-5273 (09) 00886-9/abstract. [Last accessed on 2017 Nov 01].  Back to cited text no. 11
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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