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| CASE REPORT |
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| Year : 2010 | Volume
: 56
| Issue : 3 | Page : 209-211 |
Takotsubo cardiomyopathy presenting as postoperative atrial fibrillation
NR Shah, W Wallis
Department of Cardiology, Watford General Hospital, Vicarage Road, Watford, Hertfordshire, United Kingdom
| Date of Submission | 19-Jan-2010 |
| Date of Decision | 14-Mar-2010 |
| Date of Acceptance | 27-Apr-2010 |
| Date of Web Publication | 23-Aug-2010 |
Correspondence Address:
N R Shah
Department of Cardiology, Watford General Hospital, Vicarage Road, Watford, Hertfordshire
United Kingdom
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0022-3859.68631
Takotsubo cardiomyopathy (TC) is a condition which was first acknowledged in Japan and is characterized by a reversible systolic dysfunction of the apical or mid segments of the left ventricle. Typically affecting women in the post-menopausal population, it is triggered by intense emotional, physical or medical stress. Also known as apical ballooning syndrome or stress cardiomyopathy, TC derives its name from the left ventricular angiographic appearance of a 'Takotsubo', literally translated as an 'octopus fishing trap' in Japanese. Patients often describe chest pain, have ischemic electrocardiogram (ECG) changes and positive cardiac enzymes mimicking an acute coronary syndrome. Obstructive coronary artery disease is excluded with prompt cardiac catheterization. We present the case of a 78-year-old lady, post gynecological surgery, presenting with palpitations and ECG confirming fast atrial fibrillation. Despite spontaneous cardioversion, she went on to develop ECG changes and cardiac enzyme elevations suggestive of an acute myocardial infarction. Cardiac catheterization was performed and confirmed the diagnosis of TC. It highlights an atypical presentation of TC, which can present initially as an arrhythmia in the postoperative phase as a consequence of the supraphysiological effects of elevated circulating plasma catecholamines. It reiterates the importance of prompt diagnosis and treatment to prevent cardiac decompensation in a condition poorly understood.
Keywords: Acute coronary syndrome, palpitations, takotsubo
How to cite this article:
Shah N R, Wallis W. Takotsubo cardiomyopathy presenting as postoperative atrial fibrillation. J Postgrad Med 2010;56:209-11 |
| :: 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. | Figure 1 :Electrocardiogram of patient demonstrating ST segment elevation in lead V2, ST depression and T-wave inversion (TWI) in leads aVF and III
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 | Figure 2 :(a) Left ventricular angiogram taken in systole demonstrating apical akinesia and hyperkinesis of the basal segments. The appearance is similar to a Japanese fishing octopus trap called a 'Takotsubo', (b) The left ventricular angiogram taken in diastole
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 | Figure 3 :Electrocardiogram demonstrating resolution of ST segment elevation in V2, residual TWI in leads aVF, III and V3 and prolongation of the corrected QT interval at Day 2 post angiography
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| :: 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 | | |
| 1. | Dote K, Sato H, Tateishi H, Uchida T Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: A review of 5 cases. J. Cardiol 1991;21:203-14.  |
| 2. | Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005;111:472-9. [PUBMED] [FULLTEXT] |
| 3. | Dorfman TA, Aqel R, Mahew M, Iskandrian AE. Tako-tsubo cardiomyopathy: A review of the literature. Curr Cardiol Rev 2007;3:137-42. |
| 4. | Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-48. [PUBMED] [FULLTEXT] |
[Figure 1], [Figure 2], [Figure 3]
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