Case Report

Postoperative Takotsubo cardiomyopathy Shilpa Bhojraj, Shirish Sheth1, Dev Pahlajani2 Departments of Anaesthesiology, 1Gynaecology, and 2Cardiology, Breach Candy Hospital, Mumbai, Maharashtra, India


Received: 05‑06‑13 Accepted: 05‑12‑13

Takotsubo cardiomyopathy also known as transient apical ballooning syndrome or stress induced reversible cardiomyopathy is an increasingly reported syndrome generally characterized by transient systolic dysfunction of the apical and/or mid segment of the left ventricle. It is frequently precipitated by severe stress and clinically mimics an acute ST‑elevation myocardial infarction, with angiographically normal coronary arteries. A high index of suspicion is needed to diagnose this syndrome. We describe a patient who developed Takotsubo cardiomyopathy in the post‑operative period following vaginal hysterectomy. Key words: Coronary angiography; General anesthesia; Takotsubo cardiomyopathy; Vaginal hysterectomy


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Website: PMID: *** DOI: 10.4103/0971-9784.129875 Quick Response Code:

Takotsubo cardiomyopathy also known as transient apical ballooning syndrome[1] or stress induced reversible cardiomyopathy[2] is an increasingly reported syndrome. It is frequently precipitated by severe stress and clinically mimics an acute ST‑elevation myocardial infarction with angiographically normal coronary arteries.[3,4] Takotsubo syndrome or broken heart or Gebrochenes‑Herz syndrome[5] is defined as a combination of acute chest pain, ST segment changes and transient left ventricular (LV) apical wall motion abnormalities that mimics acute myocardial infarction (MI), related to surges in catecholamine levels. It predominantly occurs in post‑menopausal women with a mean age of 58‑76 years.[6] Endothelial dysfunction in the post‑menopausal period probably increases the vulnerability to sympathetically mediated myocardial stunning in this cohort. Most of the patients survive the initial acute event with a very low rate of in‑hospital mortality or complications. Even when ventricular systolic function is heavily compromised at presentation, it typically improves within the 1st few days and normalizes within 8 weeks. This syndrome has been reported in the perioperative setting after both minor and major surgical procedures[7‑9] and can occur following regional or general

anesthesia. The authors report a patient presenting postoperatively with stress induced cardiomyopathy, which normalized over a period of 6 weeks. CASE REPORT A 56‑year‑old female, American Society of Anesthesiologists grade I, weighing 50 kg was scheduled to undergo vaginal hysterectomy. Laboratory parameters were within the normal limits. Pre‑operative electrocardiography (ECG) was normal [Figure 1a].  2D echocardiography revealed an ejection fraction (EF) of 64%. Upon pre‑operative counseling, she expressed anxiety and concern for the surgery. She was administered general anesthesia with midazolam 2 mg, fentanyl citrate 50 µg and etomidate 8 mg. Atracurium 40 mg was used to facilitate endotracheal intubation. Anesthesia was maintained with a mixture of O2:N2O (44:56), isoflurane 1‑2% and boluses of fentanyl and atracurium. The hemodynamic parameters remained stable throughout the procedure. At the end of the surgical procedure, the trachea was extubated after reversal of neuromuscular blockade. The patient was conscious and post‑operative pain was managed with intravenous tramadol 50 mg. At 3 h post transfer to the ward, she became

Address for correspondence: Dr. Shilpa Bhojraj, Department of Anaesthesiology, Breach Candy Hospital, Bhullabhai Desai Road, Mumbai ‑ 400 026, Maharashtra, India. E‑mail: [email protected]

Annals of Cardiac Anaesthesia    Vol. 17:2    Apr-Jun-2014


Bhojraj, et al.: Postoperative Takotsubo cardiomyopathy 

hemodynamically unstable‑systolic blood pressure decreased to 60 mmHg, heart rate to 60/min, and SpO2‑76%. She was resuscitated with atropine sulfate 0.6 mg, intravenous fluids and sodium bicarbonate 25 ml. Dopamine hydrochloride and noradrenaline were started at 5 µg/kg/min and 4 µg/min, respectively. ECG revealed fresh changes with ST flattening in leads II, III and aVF and ST depression with T wave inversion in leads V2‑V6 [Figure 1b] Cardiac enzymes were mildly elevated. Her white blood cell (WBC) count rose to 22,220/ul. At 5 h post‑operatively her SpO2 decreased to 70% (with 8 L of oxygen by mask), and she developed bilateral basal crepitations. Intravenous fluid intake and output showed 1775 ml and 680 ml with a positive balance of 1095 ml. The patient was immediately transferred to the intensive care unit where a central venous line was inserted through right internal jugular vein. Central venous pressure was 15 mmHg. Chest X‑ray showed fluffy shadows in middle and lower zones [Figure 2]. 2D echocardiography revealed an EF of 30‑35% with akinesia and ballooning of apex, anterior wall and distal septum. There was evidence of left ventricular (LV) diastolic dysfunction as well. In view of the decreased EF and high WBC counts, a differential diagnosis of acute coronary syndrome with LV failure/sepsis respectively was arrived at. Serum lactate and procalcitonin levels were normal. An urgent coronary angiography was performed after sedating and intubating her. Angiography revealed completely normal left and right coronary arteries [Figures 3a and b]. Arterial blood gases revealed; pH = 7.42, PaCO2 = 38 mm Hg, PaO2  =  60 mm Hg, HCO3  =  24 mm, SpO2  =  85%. She was extubated after a successful T‑tube trial after 12 h. WBC count increased to 23,760/ul. She was started on intravenous meropenam 8 hourly. 2D echocardiography showed a further fall in EF to 25%. LV diastolic dysfunction persisted (DT = 108 ms). Chest X‑ray revealed soft parenchymal opacities (She was now in a negative balance by 800 ml). In view of the ECG findings indicating myocardial ischemia, negative coronary angiography and deteriorating LV function by 2D echocardiography, she was diagnosed as a case of Takotsubo cardiomyopathy. Over the next 2‑3 days, she remained stable, inotropes and vasopressors were tapered and discontinued on the fourth post‑operative day. WBC count gradually decreased to 9890/ul. Repeat 2D echocardiography on 4th day remained the same. Her total fluid intake was restricted and furosemide was ordered if urine output decreased to 

Postoperative Takotsubo cardiomyopathy.

Takotsubo cardiomyopathy also known as transient apical ballooning syndrome or stress induced reversible cardiomyopathy is an increasingly reported sy...
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