Atypical Takotsubo Cardiomyopathy in COVID-19

Abstract

A 70-year-old man with hypertension; hyperlipidemia, type 2 diabetes, chronic obstructive pulmonary disease, atrial fibrillation, status post cardioversion, and ablation, currently in sinus rhythm, presented to the hospital with insidious onset, gradually progressive shortness of breath, and a low-grade, intermittent fever of one-week duration. On the day of the presentation, he was in moderate respiratory distress. His oxygen saturation was 85% on supplemental O2 at 6 l/min. Initial vital signs were blood pressure of 146/64 mmHg, respiratory rate of 28/minute, and pulse rate of 88/minute. Respiratory exam demonstrated reduced breath sounds bilaterally, along with mild infrascapular crackles. The electrocardiogram showed new onset T wave inversion across V1 to V6 [Figure 1a]. Chest imaging showed bilateral ground glass opacities and infiltrates. [Figure 1b, 1c]. Echocardiography showed hypokinesis of the basal region of the left ventricle with hyperkinesis of the apical region of the left ventricle consistent with a reverse Takotsubo cardiomyopathy [Figure 1d, 1e]. A diagnosis of COVID-19 was made on the basis of polymerase chain reaction (PCR) testing. The patient's clinical condition deteriorated over the next two days, and the patient eventually succumbed to COVID-19. Takotsubo cardiomyopathy (also known as broken heart syndrome, transient apical ballooning syndrome, and stress cardiomyopathy is a form of reversible cardiomyopathy. It mimics the clinical syndrome of acute myocardial infarction in the absence of coronary artery stenosis or spasm. It derives its name from the Japanese octopus fishing pot called ‘takotsubo’ to which the involved heart resembles in shape. This syndrome is most commonly seen in postmenopausal women in the presence of extreme physical or emotional stress. It is diagnosed with a typical finding of transient, reversible apical hypokinesia and associated basal hyperkinesia. Reverse Takotsubo cardiomyopathy is its variant characterized by reversible, basal akinesia/hypokinesis and associated apical hyperkinesia.1Sala S Peretto G Gramegna M et al.Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection.Eur Heart J. 2020; 41: 1861-1862Crossref PubMed Scopus (304) Google Scholar Patients with severe COVID-19 disease most commonly present with the involvement of the respiratory system. Cardiovascular involvement, including acute myocardial injury and stress-induced cardiomyopathy, has also been commonly reported in 5% of these patients.2Mishra AK Sahu KK George AA et al.A review of cardiac manifestations and predictors of outcome in patients with COVID-19 [e-pub ahead of print].Heart Lung. 2020; (, accessed August 20, 2021)https://doi.org/10.1016/j.hrtlng.2020.04.019Abstract Full Text Full Text PDF Scopus (42) Google Scholar To date, 9 patients with stress-induced cardiomyopathy secondary to COVID-19 have been reported.1Sala S Peretto G Gramegna M et al.Acute myocarditis presenting as a reverse Tako-Tsubo syndrome in a patient with SARS-CoV-2 respiratory infection.Eur Heart J. 2020; 41: 1861-1862Crossref PubMed Scopus (304) Google Scholar,3Pasqualetto MC Secco E Nizzetto M et al.Stress cardiomyopathy in COVID-19 disease.Eur J Case Rep Intern Med. 2020; 7001718https://doi.org/10.12890/2020_001718Crossref PubMed Google Scholar We report the first male patient with reverse Takotsubo cardiomyopathy secondary to COVID-19 infection. The physiologic cause of this broken heart syndrome could either have been the initial stress of acute lung injury from COVID-19 or subsequent deterioration secondary to cytokine storm.