Case Report
Figure 1: Initial Study. Two-dimensional Echocardiographic Image of Takotsubo Cardiomyopathy in the Parasternal Long Axis Projection
The American Heart Hospital Journal
measure catecholamine levels because the confounding factors of seizure, agitation, and heart failure may increase them. The patient declined our advice to have coronary angiography.
A repeated two-dimensional echocardiography obtained three months later at a clinic visit showed a dramatic normalization of the LV (Figure 2). There was no apical ballooning. The LV contour, wall motions and global systolic function (LVEF 60 %) had become normal. We performed intravenous dipyridamole myocardial perfusion imaging, which revealed no ischemic defects.
Discussion Note the apical ballooning of the left ventricle (dotted outline).
Figure 2: Follow-up Study. Echocardiographic Image after Recovery Showing Normalization of the Left Ventricular Shape
A takotsubo is a pot with a bulbous bottom and a narrow neck used by Japanese fishermen to trap octopi. TC derives its name from the altered LV shape, specifically the apical ballooning, resembling a takotsubo. The common clinical presentations are ST elevation (in 82 % of cases), acute LV failure (68 %), dyspnea (18 %), and cardiogenic shock (4 %). Life-threatening ventricular arrhythmias may occur. Although these features mimic an acute coronary event, the actual incidence of angiographically important coronary lesions is uniformly low.1
Coronary angiography was not
performed in this case because the patient declined to have this test. However, we believe that significant coronary disease was excluded by the normal exercise myocardial perfusion test images.
The pathophysiology of TC is interesting. Serious emotional or physical stresses are suggested as the etiologies of TC. Therefore, descriptive terms like ‘broken- heart syndrome’, ‘stress-induced cardiomyopathy’, and ‘catecholamine-induced cardiomyopathy’ are in use. Common causal stressors include death of a loved one, financial loss, altercation, natural catastrophe, and similar intense emotional situations.2
Current thinking is that TC
results from the ‘cardio-toxic’ effects of acutely elevated circulating epinephrine and norepinephrine levels (‘catecholamine storm’) following stress. As a result, there is myocardial stunning, cell injury, and myocytolysis.3
The
IVS = intraventricular septum; LA = left atrium; LV = left ventricle; MV = mitral valve; PW = posterior wall; RV = right ventricle.
defibrillation. Hypotension responded to pressor agents. With assisted ventilation and treatment with inotropic agents, the heart failure resolved and the ST segments became isoelectric. The routine biochemical tests were normal. The urine and blood tests were reported as negative for toxic substances. We did not
120 Life-threatening Takotsubo Cardiomyopathy
selective apical involvement in TC is explained by greater concentration of adrenergic receptors in the LV apex than in the rest of the LV segments.4
As further evidence of
catecholamine theory, the coincidence of TC and excessive catecholamine release in pheochromocytoma and cocaine use are described in the literature.5,6
The list of physical stresses, such as traumatic injury, surgical procedures, etc., resulting in TC, is extensive. In addition to physical and emotional stresses, a number of neuropsychiatric
Winter 2011
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