BACKGROUND: Takotsubo cardiomyopathy, commonly known as broken heart syndrome, is a stress-induced cardiomyopathy that mimics acute coronary syndrome, but rarely presents in the perioperative period. We present a unique... [ view full abstract ]
BACKGROUND:
Takotsubo cardiomyopathy, commonly known as broken heart syndrome, is a stress-induced cardiomyopathy that mimics acute coronary syndrome, but rarely presents in the perioperative period. We present a unique presentation of Takotsubo cardiomyophathy with severe bradycardia and ST changes intraoperatively.
CASE REPORT:
A 63 year old female with no significant cardiac history presented with left cerebellar and left frontal lobe masses scheduled for sub-occipital craniotomy. Past medical history included hypertension, type 2 diabetes, end stage renal disease, and kidney transplantation, and reported a 12-hour history of malaise. It was discovered postoperatively that she also had significant recent emotional stress with the death of a close family member. After induction of anesthesia and intubation of the trachea, the patient was positioned for surgery. Over the next few minutes she developed profound bradycardia with her heart rate decreasing from 65 bpm to 24 bpm. A wide complex QRS and increasing ST segment elevation in V5 accompanied the bradycardia which was minimally responsive to low dose epinephrine, glycopyrrolate, and atropine. Within minutes she no longer had a palpable pulse and cardiac arrest was recognized. Full ACLS resuscitation was performed with intra operative transesophageal echocardiogram showing apical ballooning of the LV with global hypokinesis. She was taken to the cardiac catheterization lab where angiography showed patent coronary arteries and elevated PA pressures. A ventricular assist device was inserted to offload the LV. Over the next 24 hours cardiac function returned to normal and the device was removed. Unfortunately, the patient was found to have suffered an anoxic brain injury during resuscitation and cardiopulmonary support was withdrawn.
CONCLUSION:
Takotsubo cardiomyopathy can be triggered by emotional stress; in this case it appears to have been exacerbated by induction of general anesthesia. Presenting signs including ST changes, hemodynamic instability, bradycardia, and cardiac collapse can mimic acute myocardial infarction. Her malaise likely reflected early symptoms. Typically, the diagnosis can be made by echocardiogram in the setting of acute coronary syndrome being ruled out on angiogram. Intraoperative bradycardia due to Takotsubo cardiomyopathy, while somewhat rare, should always be on the differential diagnosis when acute coronary syndrome is suspected.
