Abstract 13990: Even the Perfect Face Can Break Your Heart: A Case of Variant Takotsubo Cardiomyopathy After Facial Reconstruction Surgery

Abstract

Introduction: Mid and basal akinesia of the left ventricular wall is a rare variant of Takotsubo cardiomyopathy (TTC). This form of cardiomyopathy is commonly associated with severe emotional and physical triggers in post-menopausal women, but not typically in younger patients undergoing minimally invasive surgical interventions. Case Description: A 45-year-old female with prior breast augmentation surgery presented to the emergency room after an elective facial reconstruction procedure, complicated by shock. At the end of the procedure, she received a planned phenylephrine challenge by her surgeon to assess the risk of post-op bleeding, after which she developed persistent hypotension. On arrival, the patient was hypotensive, tachycardic, and requiring oxygen. The patient was started on norepinephrine and vasopressin infusions. Initial labs were notable for a troponin of 4,611. EKG showed sinus arrhythmia and diffuse ST depressions. Transthoracic echocardiogram (TTE) showed a left ventricle with moderately reduced systolic function with akinesia of mid and basal segments with preserved contractility of the apex. Left heart catheterization showed no coronary disease and an elevated left ventricular end diastolic pressure. Right heart catheterization on vasopressors revealed elevated pulmonary pressures and a Fick cardiac output/cardiac index of 4/2.3. Given elevated filling pressures, the patient received diuresis as pressors and oxygen were weaned. Prior to discharge, minimal guideline directed management therapy was started due to low blood pressures and a repeat TTE was unchanged. Discussion: This is a rare case of variant TTC associated with facial reconstruction surgery and exposure to an adrenergic agent, both atypical triggers. One hypothesized mechanism of TTC is linked to a catecholamine surge and therefore, adrenergic agonists, such as phenylephrine, and general anesthetics have been reported as contributing to the risk of developing TTC. This case further creates awareness for this syndrome as a post-procedural complication and cause of shock, despite minimal invasiveness and prior tolerance to similar interventions. Additionally, further research of catecholamine drugs as possible risk factors is needed.