Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 56, Num. 3, 2010, pp. 209-211

Journal of Postgraduate Medicine, Vol. 56, No. 3, July-September, 2010, pp. 209-211

Case Report

Takotsubo cardiomyopathy presenting as postoperative atrial fibrillation

Shah NR, Wallis W

Department of Cardiology, Watford General Hospital, Vicarage Road, Watford, Hertfordshire, UK

Correspondence Address: Dr. Nikunj R Shah, Department of Cardiology, Watford General Hospital, Vicarage Road, Watford, Hertfordshire, UK, nikunjravshah@hotmail.com

Date of Submission: 19-Jan-2010
Date of Decision: 14-Mar-2010
Date of Acceptance: 27-Apr-2010

Code Number: jp10057

PMID: 20739768

DOI: 10.4103/0022-3859.68631

Abstract

Keywords: Acute coronary syndrome, palpitations, takotsubo

Introduction

Takotsubo cardiomyopathy' (TC) is a condition which was first described in Japan, characterized by a transient systolic dysfunction of the apical or mid segments of the left ventricle (LV). ^[1] Also known as 'stress-induced cardiomyopathy', 'broken-heart syndrome', 'ampulla cardiomyopathy' or 'apical ballooning syndrome', it has a female predilection, particularly in the post-menopausal population and is typically triggered by intense medical, physical or emotional stress. Patients often describe chest pain, have ST segment elevation on electrocardiogram (ECG), and elevated cardiac enzymes mimicking an acute coronary event. However, coronary angiography shows unobstructed coronary arteries with a characteristic left ventricular angiogram resembling an 'octopus pot', or in Japanese, a 'Takotsubo'. It is an important differential of acute myocardial infarction (AMI) and with appropriate treatment tends to have a favorable prognosis. Hence, to expedite appropriate management, clinicians need to understand and recognize this condition.

Case Report

We describe the case of a 78-year-old Caucasian lady complaining of palpitations at Day 3 post total abdominal hysterectomy and bilateral salpingo-oophorectomy for endometrial adenocarcinoma. She was hemodynamically stable but found to be in atrial fibrillation with a fast ventricular rate of 140 beats per min, confirmed by ECG. Significant past medical history included tablet-controlled Type 2 diabetes, urinary incontinence and obesity. She spontaneously cardioverted and was started on Bisoprolol at 1.25 milligrams. Despite being asymptomatic, subsequent ECGs demonstrated a 2 mm ST segment elevation in lead V2, down-sloping ST segment depression and T-wave inversions in leads III and aVF [Figure - 1]. A peak troponin I was elevated at 1.69 ΅g/L (negative <0.04 ΅g/L), and in the absence of renal dysfunction, urgent cardiac catheterization was recommended after initial treatment with aspirin, clopidogrel and low molecular weight heparin. This revealed normal coronary arteries, but a left ventricular angiogram demonstrated extensive apical hypokinesia, basal hyperkinesis and an estimated ejection fraction of 40%, indicative of TC [Figure - 2]a and b. ECG at two days following angiography demonstrated a resolution in ST segment elevation in V2, T-wave inversion in lead V3 and a prolongation of the corrected QT interval [Figure - 3]. The patient remained well throughout her stay and was discharged on a betablocker, angiotensin converting enzyme (ACE) inhibitor and statin therapy. Her recovery was uneventful and at follow-up echocardiography four weeks later, her regional left ventricular wall motion abnormality had resolved.

Discussion

Acute stress-induced cardiomyopathy or apical ballooning syndrome is increasingly recognized due to early and primary coronary intervention revealing normal coronary arteries with a characteristic left ventricular angiographic appearance of an 'octopus pot'. ^[2] The LV dysfunction is usually confined to the apex, however variants have been reported as presenting with basal ballooning, which spares the mid-LV region and demonstrates apical hyperkinesis. Reported ECG changes range from ST segment elevation, T-wave inversion, ST segment depression, atrial and ventricular arrythmias, and a prolonged QT interval.

Post menopausal women tend to be most commonly affected with intense emotional or physical stress implicated as a causative factor. ^[3] The pathogenesis is not well understood but possible theories include catecholamine induced ventricular dysfunction, multi vessel coronary arterial vasopasm and microvascular spasm, and dynamic left ventricular outflow tract obstruction with consequent catecholamine release. Of these hypotheses, exaggerated catecholamine-induced myocardial stunning is best supported as a cause of the transient left ventricular dysfunction. ^[4]

Prognosis tends to be excellent, with in hospital mortality quoted at less than 1%, provided appropriate management is initiated early on. ^[3] Urgent coronary angiography should be performed to exclude AMI and betablocker therapy should be initiated as soon as possible. In the absence of a significant left ventricular outflow tract (LVOT) obstruction, ACE inhibitors and diuretics can be used if necessary. Rare complications include cardiogenic shock, LV thrombus, LVOT obstruction, LV free wall rupture and patients should be closely monitored for signs of decompensation in the peri-acute period. Intra-aortic balloon pumps may be required in compromised patients requiring hemodynamic support.

This case highlights acute physical stress as a potent trigger for myocardial dysfunction. Usually documented as presenting after an emotional stressor, it is important to note that postoperative patients are in a vulnerable cohort susceptible to cardiac dysfunction due to the elevated levels of circulating catecholamines in the peri-operative period. It also emphasizes that initial presentations of TC may involve atrial arrhythmias in addition to the commoner presentations mimicking acute coronary syndromes. Although catecholamine-induced myocardial stunning is proposed as a probable mechanism, precise understanding of this condition will require further research. Despite its increasing global recognition, it still remains poorly understood. In order to maintain its favorable prognosis, optimal management needs to be initiated early and is reliant on prompt diagnosis.

References

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