Don't Break My Heart: A Case Report of Takotsubo Syndrome in a Transplanted Heart

Abstract

Cardiogenic shock after heart transplant, could be due to acute rejection, cardiac allograft vasculopathy, or myocarditis. Stress cardiomyopathy (CM) in a denervated transplanted heart is unusual. A 56-year-old man with a history of ischemic heart disease and a seizure disorder underwent orthotropic heart transplant. He had breakthrough seizures posttransplant while on levetiracetam (Keppra) and was admitted for status epilepticus. A transthoracic echocardiogram (TTE) was done for hypotension (BP 90/60). TTE showed a severely reduced left ventricular ejection fraction (LVEF) of 15%, hyperkinetic base, and apical ballooning that are consistent with stress CM. Electrocardiogram with T wave inversion in precordial leads. Troponin was elevated to 1.77. The patient had cardiogenic shock and needed an intra-aortic balloon pump and multiple pressors. He was treated for status epilepticus and the LVEF completely recovered in 1 week. The patient had a normal TTE, coronary angiography, and biopsy with no rejection 8 days before admission. Stress CM was the diagnosis of exclusion, confirmed with a complete recovery of the LVEF. There are only 5 case reports of stress CM after heart transplant, with most presenting 9 to 10 years afterwards. We describe an unusual case of cardiogenic shock from stress CM triggered by status epilepticus in a denervated heart only 1 year posttransplant. The mechanism is elusive, and some hypotheses suggest exaggerated sensitivity to a plasma catecholamine surge from parasympathetic denervation. In a denervated heart, autonomic re-innervation can be seen as early as 1 year posttransplant.