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Atypical variant of takotsubo cardiomyopathy during perioperative period – A rare case
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y x x x ( 2 0 1 5 ) 1 e3
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jicc
Case Report
Atypical variant of takotsubo cardiomyopathy during perioperative period e A rare case Ankur Thummar*, Umesh Khedkar, Ajay Mahajan, Yash Lokhandwala, Pratap Nathani Department of Cardiology, LTMMC & General Hospital, Sion, Mumbai 22, Maharashtra, India
article info
abstract
Article history:
Takotsubo cardiomyopathy, is characterized by transient left ventricular dysfunction and
Received 23 April 2015
electrocardiographic changes that might mimic acute myocardial infarction in the
Accepted 30 April 2015
absence of significant obstructive coronary artery disease. Typical takotsubo cardiomy-
Available online xxx
opathy (TCM) is associated with a ballooned left ventricular (LV) apex with basal segmental hyperkinesis. The adrenergic discharge during or after anaesthesia may gives
Keywords:
rise to transient ventricular dysfunction. We report a case of atypical takotsubo cardio-
Takotsubo cardiomyopathy
myopathy, presented as LV global hypokinesia following general anaesthesia. This rare
Atypical variant
and atypical variant of stress induced cardiomyopathy is rarely reported in english
General anaesthesia
literature. Copyright © 2015, Indian College of Cardiology. All rights reserved.
1.
Introduction
Takotsubo cardiomyopathy (TCM) was first described in Japan by Sato et al. in 1990, named after a contraption used for catching octopuses. The disease is also known as left ventricular (LV) apical ballooning, broken heart syndrome, stressinduced cardiomyopathy, and ampulla cardiomyopathy.1,2 While the initial description was that of reversible aneurysm involving the distal LV myocardium, more recently variant forms limited to mid or basal regions have been described. Recently few case reports of global LV hypokinesia variant are also described. But association of this variant with general anaesthesia is rarer still.
2.
Case report
A 39 years lady was admitted in urology department for PCNL with bilateral hydronephrosis secondary to bilateral stag horn calculi. She had no risk factors of coronary artery disease. The patient was taken for procedure with required pre-operative work-up. Soon after induction of general anaesthesia with intravenous propofol (2e2.5 mg/kg) and fentanyl (3 micrograms/kg), the patient went into acute left ventricular failure (LVF). Her vital parameters revealed sinus tachycardia (HR160 bpm), hypotension (B.P. 80/50 mmhg). Her oxygen saturation was dropped from 97% to 80% on pulse oxymetry. Examination revealed bilateral extensive crepitation.
* Corresponding author. Department of Cardiology, Casualty Building 2nd floor, LTMMC & General Hospital, Sion, Mumbai 22, Maharashtra, India. Tel.:þ91 7498994924. E-mail address: [email protected] (A. Thummar). http://dx.doi.org/10.1016/j.jicc.2015.04.006 1561-8811/Copyright © 2015, Indian College of Cardiology. All rights reserved.
Please cite this article in press as: Thummar A, et al., Atypical variant of takotsubo cardiomyopathy during perioperative period e A rare case, Journal of Indian College of Cardiology (2015), http://dx.doi.org/10.1016/j.jicc.2015.04.006
2
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y x x x ( 2 0 1 5 ) 1 e3
Fig. 1 e A e 12 lead ECG during acute phase showed T inversion in lead I and aVL, Tall T in V3eV4 (lead V2 was not demonstrated due to technical problem) B e 12 lead ECG after recovery showed no significant ST e T changes.
Immediately, the patient was intubated and mechanical ventilation was started. Additionally, She was given inotropes (dopamine 5e7 mcg/kg/min), pressure supports (noradrenaline 2e4 mcg/min) and intravenous bolus of loop diuretic (furosemide 40 mg). Her ECG revealed T wave inversion in lead I and aVL with ST depression in precordial leads.(Fig. 1) Cardiac enzyme assay showed elevated Troponin T level of 1.01 ng/ml (Normal reference limit <0.014 ng/ml) and NT pro BNP level of 1130 pg/ml (Normal reference limit <300 pg/ml).
Transthoracic echocardiography revealed severe global left ventricular (LV) hypokinesia with dyskinetic apical movement and LV ejection fraction of 25e30% with LV apical clot. (solid arrow in Fig. 2:C,D; video 1,2) Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jicc.2015.04.006. The patient was weaned gradually from ventilator and inotropic support with invasive haemodynamic monitoring.
Fig. 2 e Upper Panel (Acute phase): C, D e Apical 4 chamber view (A4C) by two-dimensional echocardiography in end systole (C) and end diastole (D) revealed global dilatation of left ventricular (LV) cavity with elevated end diastolic volume (EDV) and end systolic volume (ESV) with LV apical clot (solid arrow). E e M mode echo of mitral valve (MV) in parasternal short axis view showed severly compromise LV systolic function & LVEF ¼ 27% (by Teich-holz method). Lower Panel (After recovery): F, G e A4C view in systole (F) and diastole (G) showed LV cavity and volumes normalized and good seperation of IVS & lateral wall compare to fig. C,D. HeM mode across MV in parasternal long axis view demonstrated recovered LV function with LVEF ¼ 67%. Please cite this article in press as: Thummar A, et al., Atypical variant of takotsubo cardiomyopathy during perioperative period e A rare case, Journal of Indian College of Cardiology (2015), http://dx.doi.org/10.1016/j.jicc.2015.04.006
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y x x x ( 2 0 1 5 ) 1 e3
Her haemodynamic parameters were stabilised and LV function was normalized, which was demonstrated by echocardiography after one week of index event. (Fig. 2:F,G,H; video 3,4) Subsequently Coronary Angiogram was done at day 8, showed normal coronaries and LV angiogram showed normal LV ejection fraction. Patient was discharged on oral anticoagulation in stable and asymptomatic condition on 10th day of hospitalisation. Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jicc.2015.04.006.
3.
Discussion
The onset of stress cardiomyopathy is frequently but not always triggered by an acute medical illness or by intense emotional or physical stress.2,3 Very few case reports denoted general anaesthesia as a trigger for TCM.4 Postulated mechanisms include catecholamine excess, coronary artery spasm, and micro vascular dysfunction. In reported case, surgical stress, intubation, anaesthetic drugs might be responsible for adrenergic discharge and thus TCM. While going through the literature, there are no enough data to label anaesthetic agents as a causative factor for TCM. So we concluded that association of TCM with general anaesthetic agents is merely an association rather than causative factor in our case.4,5 There is no consensus on the diagnostic criteria for takotsubo cardiomyopathy. The researchers at the Mayo Clinic proposed diagnostic criteria in 2004, which have been modified recently as follows5: (1) transient hypokinesis, akinesis, or dyskinesis in the left ventricular mid segments with or without apical involvement; regional wall motion abnormalities that extend beyond a single epicardial vascular distribution; and frequently, but not always, a stressful trigger; (2) the absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; (3) new ECG abnormalities (ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin; and (4) the absence of pheochromocytoma and myocarditis. The case reported hereby had all the features of stress induced cardiomyopathy except absence of regional wall motion abnormalities. Another unusual feature our patient had LV clot formation, which had been reported with this entity but not so
3
commonly. Stress-induced cardiomyopathy may, thus present in different forms, including regional or global left ventricular dysfunction. Classic takotsubo syndrome may represent only part of the spectrum of this reversible condition.4,5 Treatment is supportive and prognosis is generally good as many the patients recover their LVEF within few weeks to months.
4.
Conclusion
The global LV hypokinesia represent atypical form of stressinduced cardiomyopathy and frequently underreported variant. It is possible that systemic catecholamine release triggered by precipitating factors can produce any degree of transient ventricular hypokinesis which may or may not be regional. To conclude with, takotsubo cardiomyopathy is only a part of this more general stress-induced cardiomyopathy syndrome and its association with general anaesthesia to be kept in mind during surgical procedure.
Conflicts of interest All authors have none to declare.
references
1. Sato H, Taiteishi H, Uchida T. Takotsubo-type cardiomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M, eds. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Tokyo: Kagakuhyouronsha; 1990:56. 2. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539e548. 3. Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation. 2005;111:472e479. 4. Wong AK, Vernick WJ, Wiegers SE, Howell JA, Sinha AC. Preoperative takotsubo cardiomyopathy identified in the operating room before induction of anesthesia. Anesth Anal. 2010;110:712e715. 5. Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation. 2008;118(4):39.
Please cite this article in press as: Thummar A, et al., Atypical variant of takotsubo cardiomyopathy during perioperative period e A rare case, Journal of Indian College of Cardiology (2015), http://dx.doi.org/10.1016/j.jicc.2015.04.006
Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.elsevier.com/locate/jicc
Case Report
Atypical variant of takotsubo cardiomyopathy during perioperative period e A rare case Ankur Thummar*, Umesh Khedkar, Ajay Mahajan, Yash Lokhandwala, Pratap Nathani Department of Cardiology, LTMMC & General Hospital, Sion, Mumbai 22, Maharashtra, India
article info
abstract
Article history:
Takotsubo cardiomyopathy, is characterized by transient left ventricular dysfunction and
Received 23 April 2015
electrocardiographic changes that might mimic acute myocardial infarction in the
Accepted 30 April 2015
absence of significant obstructive coronary artery disease. Typical takotsubo cardiomy-
Available online xxx
opathy (TCM) is associated with a ballooned left ventricular (LV) apex with basal segmental hyperkinesis. The adrenergic discharge during or after anaesthesia may gives
Keywords:
rise to transient ventricular dysfunction. We report a case of atypical takotsubo cardio-
Takotsubo cardiomyopathy
myopathy, presented as LV global hypokinesia following general anaesthesia. This rare
Atypical variant
and atypical variant of stress induced cardiomyopathy is rarely reported in english
General anaesthesia
literature. Copyright © 2015, Indian College of Cardiology. All rights reserved.
1.
Introduction
Takotsubo cardiomyopathy (TCM) was first described in Japan by Sato et al. in 1990, named after a contraption used for catching octopuses. The disease is also known as left ventricular (LV) apical ballooning, broken heart syndrome, stressinduced cardiomyopathy, and ampulla cardiomyopathy.1,2 While the initial description was that of reversible aneurysm involving the distal LV myocardium, more recently variant forms limited to mid or basal regions have been described. Recently few case reports of global LV hypokinesia variant are also described. But association of this variant with general anaesthesia is rarer still.
2.
Case report
A 39 years lady was admitted in urology department for PCNL with bilateral hydronephrosis secondary to bilateral stag horn calculi. She had no risk factors of coronary artery disease. The patient was taken for procedure with required pre-operative work-up. Soon after induction of general anaesthesia with intravenous propofol (2e2.5 mg/kg) and fentanyl (3 micrograms/kg), the patient went into acute left ventricular failure (LVF). Her vital parameters revealed sinus tachycardia (HR160 bpm), hypotension (B.P. 80/50 mmhg). Her oxygen saturation was dropped from 97% to 80% on pulse oxymetry. Examination revealed bilateral extensive crepitation.
* Corresponding author. Department of Cardiology, Casualty Building 2nd floor, LTMMC & General Hospital, Sion, Mumbai 22, Maharashtra, India. Tel.:þ91 7498994924. E-mail address: [email protected] (A. Thummar). http://dx.doi.org/10.1016/j.jicc.2015.04.006 1561-8811/Copyright © 2015, Indian College of Cardiology. All rights reserved.
Please cite this article in press as: Thummar A, et al., Atypical variant of takotsubo cardiomyopathy during perioperative period e A rare case, Journal of Indian College of Cardiology (2015), http://dx.doi.org/10.1016/j.jicc.2015.04.006
2
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y x x x ( 2 0 1 5 ) 1 e3
Fig. 1 e A e 12 lead ECG during acute phase showed T inversion in lead I and aVL, Tall T in V3eV4 (lead V2 was not demonstrated due to technical problem) B e 12 lead ECG after recovery showed no significant ST e T changes.
Immediately, the patient was intubated and mechanical ventilation was started. Additionally, She was given inotropes (dopamine 5e7 mcg/kg/min), pressure supports (noradrenaline 2e4 mcg/min) and intravenous bolus of loop diuretic (furosemide 40 mg). Her ECG revealed T wave inversion in lead I and aVL with ST depression in precordial leads.(Fig. 1) Cardiac enzyme assay showed elevated Troponin T level of 1.01 ng/ml (Normal reference limit <0.014 ng/ml) and NT pro BNP level of 1130 pg/ml (Normal reference limit <300 pg/ml).
Transthoracic echocardiography revealed severe global left ventricular (LV) hypokinesia with dyskinetic apical movement and LV ejection fraction of 25e30% with LV apical clot. (solid arrow in Fig. 2:C,D; video 1,2) Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jicc.2015.04.006. The patient was weaned gradually from ventilator and inotropic support with invasive haemodynamic monitoring.
Fig. 2 e Upper Panel (Acute phase): C, D e Apical 4 chamber view (A4C) by two-dimensional echocardiography in end systole (C) and end diastole (D) revealed global dilatation of left ventricular (LV) cavity with elevated end diastolic volume (EDV) and end systolic volume (ESV) with LV apical clot (solid arrow). E e M mode echo of mitral valve (MV) in parasternal short axis view showed severly compromise LV systolic function & LVEF ¼ 27% (by Teich-holz method). Lower Panel (After recovery): F, G e A4C view in systole (F) and diastole (G) showed LV cavity and volumes normalized and good seperation of IVS & lateral wall compare to fig. C,D. HeM mode across MV in parasternal long axis view demonstrated recovered LV function with LVEF ¼ 67%. Please cite this article in press as: Thummar A, et al., Atypical variant of takotsubo cardiomyopathy during perioperative period e A rare case, Journal of Indian College of Cardiology (2015), http://dx.doi.org/10.1016/j.jicc.2015.04.006
j o u r n a l o f i n d i a n c o l l e g e o f c a r d i o l o g y x x x ( 2 0 1 5 ) 1 e3
Her haemodynamic parameters were stabilised and LV function was normalized, which was demonstrated by echocardiography after one week of index event. (Fig. 2:F,G,H; video 3,4) Subsequently Coronary Angiogram was done at day 8, showed normal coronaries and LV angiogram showed normal LV ejection fraction. Patient was discharged on oral anticoagulation in stable and asymptomatic condition on 10th day of hospitalisation. Supplementary video related to this article can be found at http://dx.doi.org/10.1016/j.jicc.2015.04.006.
3.
Discussion
The onset of stress cardiomyopathy is frequently but not always triggered by an acute medical illness or by intense emotional or physical stress.2,3 Very few case reports denoted general anaesthesia as a trigger for TCM.4 Postulated mechanisms include catecholamine excess, coronary artery spasm, and micro vascular dysfunction. In reported case, surgical stress, intubation, anaesthetic drugs might be responsible for adrenergic discharge and thus TCM. While going through the literature, there are no enough data to label anaesthetic agents as a causative factor for TCM. So we concluded that association of TCM with general anaesthetic agents is merely an association rather than causative factor in our case.4,5 There is no consensus on the diagnostic criteria for takotsubo cardiomyopathy. The researchers at the Mayo Clinic proposed diagnostic criteria in 2004, which have been modified recently as follows5: (1) transient hypokinesis, akinesis, or dyskinesis in the left ventricular mid segments with or without apical involvement; regional wall motion abnormalities that extend beyond a single epicardial vascular distribution; and frequently, but not always, a stressful trigger; (2) the absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; (3) new ECG abnormalities (ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin; and (4) the absence of pheochromocytoma and myocarditis. The case reported hereby had all the features of stress induced cardiomyopathy except absence of regional wall motion abnormalities. Another unusual feature our patient had LV clot formation, which had been reported with this entity but not so
3
commonly. Stress-induced cardiomyopathy may, thus present in different forms, including regional or global left ventricular dysfunction. Classic takotsubo syndrome may represent only part of the spectrum of this reversible condition.4,5 Treatment is supportive and prognosis is generally good as many the patients recover their LVEF within few weeks to months.
4.
Conclusion
The global LV hypokinesia represent atypical form of stressinduced cardiomyopathy and frequently underreported variant. It is possible that systemic catecholamine release triggered by precipitating factors can produce any degree of transient ventricular hypokinesis which may or may not be regional. To conclude with, takotsubo cardiomyopathy is only a part of this more general stress-induced cardiomyopathy syndrome and its association with general anaesthesia to be kept in mind during surgical procedure.
Conflicts of interest All authors have none to declare.
references
1. Sato H, Taiteishi H, Uchida T. Takotsubo-type cardiomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M, eds. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Tokyo: Kagakuhyouronsha; 1990:56. 2. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539e548. 3. Sharkey SW, Lesser JR, Zenovich AG, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation. 2005;111:472e479. 4. Wong AK, Vernick WJ, Wiegers SE, Howell JA, Sinha AC. Preoperative takotsubo cardiomyopathy identified in the operating room before induction of anesthesia. Anesth Anal. 2010;110:712e715. 5. Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation. 2008;118(4):39.
Please cite this article in press as: Thummar A, et al., Atypical variant of takotsubo cardiomyopathy during perioperative period e A rare case, Journal of Indian College of Cardiology (2015), http://dx.doi.org/10.1016/j.jicc.2015.04.006