Ann Thorac Surg 2009;88:e63-e65. doi:10.1016/j.athoracsur.2009.09.070
© 2009 The Society of Thoracic Surgeons
Case Reports
Takotsubo Cardiomyopathy After Coronary Intervention Developed During Hospitalization
Jamal Hussain, MD*,
Nathan Laufer, MD,
Suzane Sorrof, MD,
Ashish Pershad, MD
Division of Cardiology, Banner Good Samaritan Medical Center, Phoenix, Arizona
Accepted for publication September 28, 2009.
* Address correspondence to Dr Hussain, 1717 S Dorsey Ln, #2010, Tempe, AZ 85281 (Email: xnorbeht{at}yahoo.com).
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Abstract
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Stress-induced cardiomyopathy is an increasingly recognized syndrome characterized by transient apical or midventricular dysfunction that mimics myocardial infarction in the absence of significant coronary artery disease. We describe a case of takotsubo syndrome that developed in an anxious patient within a few hours after a coronary interventional procedure. We believe that this will be the first case of takotsubo syndrome that developed in an inpatient after a coronary procedure, who was very concerned and anxious before the procedure.
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Introduction
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Takotsubo cardiomyopathy, also known as the "transient left ventricular apical ballooning syndrome," is an uncommon phenomenon originally described in the Japanese population in 1991 [1]. The pathophysiological mechanism is likely catecholamine overload. It was recently reported that approximately 29% of patients with this form of cardiomyopathy have coexisting coronary disease [2]. This syndrome also called broken heart syndrome and has been predominantly described in association with mental stress and natural disasters; however, recently some cases associated with acute medical illnesses have been described.
A 78-year-old woman with a medical history of hypertension and coronary artery disease was admitted to the hospital for elective coronary angiography and possible intervention. However, she had recurrent symptoms and wanted a second opinion regarding coronary revascularization. She appeared concerned and anxious regarding her condition. A diagnostic coronary angiogram was performed, and she was found to have severe diffuse disease of the left anterior descending artery (LAD). She underwent an LAD stenting with multiple endeavor drug-eluting stents and had excellent results and a final thrombolysis in myocardial infarction (TIMI) 3 flow. A left ventriculography revealed normal systolic function. The right coronary artery and the left circumflex artery had mild luminal irregularities without angiographic obstructive lesions. The procedure was uneventful. Approximately 3 hours post-procedure, she had hypotension and transient vague chest and epigastric discomfort develop, which resolved after the patient vomited. She was treated with intravascular fluid and dopamine. Serial electrocardiograms were done and an emergency echocardiogram was obtained. The second electrocardiogram revealed poor R wave progression in precordial leads compared with an earlier electrocardiogram (Figs 1A and 1B). The echocardiogram revealed mid-distal anterior and anteroapical and apical inferior wall hypokinesis with apical ballooning pattern. Her hypotension resolved. Although acute stent thrombosis was suspected, due to the transient nature of her symptoms and insignificant electrocardiographic findings, it was unlikely, therefore conservative management and observation was suggested. Overnight serial cardiac markers were elevated (peak values: creatine kinase, 800 IU/L, MB 181 ng/mL; troponin, 15.87 ng/mL) and a decision was made to perform a coronary angiogram and assess for possible stent thrombosis. A repeat coronary angiography revealed a widely patent stent and TIMI 3 flow in the LAD (Fig 2A). To our surprise, the left ventriculography revealed an apical ballooning pattern (Figs 2B and 2C). Due to the normal flow in the LAD, it was unlikely to suspect transient LAD thrombosis, and the extensive wall motion abnormality could not be explained on that basis. The patient's remaining hospital course was uneventful, and she was discharged home in stable condition on beta blockers, in addition to other necessary medications. A subsequent echocardiogram 4 weeks later revealed normal left ventricular systolic function and wall motion.
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Fig 1. (A) Baseline electrocardiogram. (B) Electrocardiogram when patient had symptoms developed after stenting. Relatively poor R wave progression in the anterior leads.
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Fig 2. Angiograms on postoperative day one showing patent stent in the left anterior descending artery (LAD) and newly developed apical ballooning. (A) The LAD showing patent stent and normal flow. (B) Left ventricle end-diastolic right anterior oblique view. (C) Apical ballooning with hypercontractile basal segments during systole, usually seen in Takotsubo syndrome.
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Comment
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Takotsubo cardiomyopathy was first described in Japan [3]. Subsequently, it has been reported in the non-Asian population. The name of the disorder is taken from the Japanese name for an octopus trap, which has a shape similar to the apical ballooning configuration of the left ventricle in the apical form of this disorder. Typical apical wall motion abnormality is seen in only 60% of patients. An atypical midventricular pattern has been described in approximately 40% of cases [4]. This disorder is much more common with women in comparison with men, and the mean age of onset is 62 to 75 years. The exact mechanism of this disorder is not well understood. Catecholamines may play an important role in the genesis of this disorder, as illustrated by a small case series showing significantly increased plasma epinephrine and norepinephrine. These patients also tend to be prone to coronary vasospasm induced by excess catecholamines. Treatment is usually supportive and beta blockers may be helpful. The disorder is typically reversible in a few weeks. Care should be taken to avoid precipitation of left ventricle outflow tract obstruction in a subset of patients with hyperkinetic basal segments [5, 6]. Vasopressors should be avoided if possible, and an intra-aortic balloon pump may be helpful in case of hemodynamic compromise.
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Acknowledgments
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We thank Frank Wallace for his assistance with the production of this article.
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References
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- Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases J Cardiol 1991;21:203-214.[Medline]
- Winchester DE, Ragosta M, Taylor AM. Concurrence of angiographic coronary artery disease in patients with apical ballooning syndrome Catheter Cardiovasc Interv 2008;72:612-616.[Medline]
- Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel coronary spasm: a review of 5 cases J Cardiol 1991;21:203-214.[Medline]
- Kurowski V, Kaiser A, von Hof K, et al. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis Chest 2007;132:809-816.[Abstract/Free Full Text]
- Tsuchihshi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: A novel heart syndrome mimicking acute infarction J Am Coll Cardiol 2001;38:11-18.[Abstract/Free Full Text]
- Akashi YJ, Nakawak K, Sakakibara M, et al. The clinical features of takotsubo cardiomyopathy Q J Med 2003;96:563-573.[Abstract/Free Full Text]
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Abstract
Introduction
