Cardiac arrest after liver transplantation in a patient with takotsubo cardiomyopathy

Abstract

Editor'We report a patient, 52-yr-old male, with normal pre-transplant cardiac workup who underwent orthotopic liver transplantation for end-stage liver disease due to haemochromatosis and alcohol use. The procedure was uncomplicated with a normal transoesophageal echocardiogram; however, the patient developed pulseless ventricular tachycardia after surgical closure. Cardiopulmonary resuscitation was performed with return of spontaneous circulation within 60 s. He was transferred to the intensive care unit (ICU) on amiodarone, norepinephrine, and vasopressin infusions. He was in sinus tachycardia 100–117 beats min−1, with central venous pressure 14–16 cm H2O, pulmonary artery systolic pressure 38–42 cm H2O, and cardiac output 7–10 litre min−1. Initial troponin level was 0.22 ng ml−1 and electrocardiogram showed new anteroseptal Q waves with minimal ST elevation and lateral T wave inversions. Immediate bedside transthoracic echocardiogram exhibited mid-to-distal and apical akinesia. Basal segments exhibited preserved wall function, but overall ejection fraction remained 25%. Left heart catheterization was performed, which showed no arterial stenosis or occlusions. Takotsubo cardiomyopathy was diagnosed and vasopressors were changed to milrinone and phenylephrine. Troponin level peaked at 7.48 ng ml−1 on postoperative day 1. The patient was extubated and weaned off milrinone and phenylephrine on postoperative day 5. Echocardiogram was unchanged on postoperative day 6 but showed normal cardiac function when repeated on postoperative day 18 (Fig. 1a–d). Meanwhile, liver function tests continually improved from the day of surgery, and the transaminases were normal by postoperative day 9. Takotsubo cardiomyopathy, also known as transient apical ballooning syndrome, stress-induced cardiomyopathy, or ‘broken heart syndrome,’ gets its name from the Japanese word for ‘fishing pot for trapping octopus’, based on the pathological appearance of the left ventricle.1Wittstein IS Thiemann DR Lima JAC et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2370) Google Scholar It was first described in Japan over 20 yr ago and since then has been described in a variety of clinical scenarios. The most common pathological finding is focal myocytolysis. The cardiomyopathy is distinctive because the apical wall of the left ventricle is affected, but the base is spared. Some have proposed that the apex is more vulnerable due to its limited elasticity reserve from not having a three layered myocardial configuration.2Mori HH Ishikawa SS Kojima SS et al.Increased responsiveness of left ventricular apical myocardium to adrenergic stimuli.Cardiovasc Res. 1993; 27: 192-198Crossref PubMed Scopus (312) Google Scholar Moreover, the apex has a limited coronary circulation and its increased β-receptor density makes it more sensitive to adenylate stimulation. The most common characteristics are: predominant occurrence in elderly or post-menopausal women;ST elevation/depression or T wave changes;onset after an acute emotional stress or an acute medical condition;prolonged QT interval;akinesis of the apical and distal anterior wall and hypercontraction of the basal wall;mild increase in cardiac enzymes;complete resolution of apical wall motions abnormality and the depressed left ventricular systolic function.1Wittstein IS Thiemann DR Lima JAC et al.Neurohumoral features of myocardial stunning due to sudden emotional stress.N Engl J Med. 2005; 352: 539-548Crossref PubMed Scopus (2370) Google Scholar Cases of takotsubo cardiomyopathy have been reported in the setting of liver transplantation,3Tachotti Pires LJ Cardoso Curiati MN Vissoci Reiche F et al.Stress-induced cardiomyopathy (takotsubo cardiomyopathy) after liver transplantation-report of two cases.Transplant Proc. 2012; 44: 2497-2500Abstract Full Text Full Text PDF PubMed Scopus (38) Google Scholar but this is the first description presenting as cardiac arrest immediately after transplantation. Awareness of the condition and early echocardiographic evaluation are imperative for making this diagnosis. The condition can have a good prognosis if diagnosed early and aggressive supportive management is initiated. The expanding use of point-of-care ultrasound in the ICU will likely lead to increased recognition of this condition. None declared.