TAKOTSUBO CARDIOMYOPATHY AND CARDIAC ARREST DURING ELECTIVE HYSTERECTOMY AND BILATERAL OOPHORECTOMY

Abstract

SESSION TITLE: Medical Student/Resident Cardiovascular Disease Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Takotsubo cardiomyopathy is a form of transient ventricular dysfunction due to severe emotional or physiologic stress. The condition often mimics that of ACS in symptomatology, EKG findings, and elevation of cardiac enzymes. The physiologic mechanism is unknown but is suspected to be related to excess catecholamine release (1). Post-anesthesia Takotsubo has been reported but the pathophysiology here is also not well established (2). Takotsubo-related life-threatening arrhythmias and/or cardiac arrest are sequelae that may be encountered (7). CASE PRESENTATION: A 44yo F (G7P3) with no significant PMH underwent elective total abdominal hysterectomy and bilateral salpingo-oopherectomy for large uterine fibroid and ovarian endometrioma. 25-30 minutes after induction with midazolam, propofol, and rocuronium, the patient’s end-tidal CO2 declined sharply with subsequent hypoxia, hypotension and cardiac arrest. Patient developed multiple episodes of VT/VF, with continued hypoxia and hemodynamic instability despite multiple doses of IV epinephrine and bicarbonate. Bedside echo showed severely decreased EF. She was stabilized with VA ECMO and underwent left heart catheterization and pulmonary angiography, which revealed small distal coronary emboli and small sub-segmental pulmonary embolism. An hour later she developed DIC with signs of abdominal compartment syndrome. After coagulopathy was reversed, she was taken to OR for decompression and completion of initial procedure. Echo the next day showed EF of 25% with apical hypokinesis. 3 days later ECMO was decannulated on and patient was extubated the following day. Echo on hospital day 5 showed EF of 35% with appearance of stress induced cardiomyopathy and no septal defects. DISCUSSION: This case is unique for the intra-operative onset of anesthesia-induced Takotsubo cardiomyopathy with cardiac arrest and coronary artery/pulmonary artery emboli. In our research, we found 8 case reports of Takotsubo after anesthesia induction (1-6). However, none of these described a gynecologic procedure as in our case. CONCLUSIONS: Further research is needed to understand the pathophysiologic relationship between Takotsubo cardiomyopathy and anesthesia induction. Reference #1: Consales, G & Campiglia, L & Michelagnoli, G & Gallerani, E & Rinaldi, S & Pace, S & Gaudio, A. (2008). Acute Left Ventricular Dysfunction Due To Takotsubo Syndrome after Induction of General Anesthesia. Minerva anestesiologica. 73. 655-8. Reference #2: Littlejohn FC, Syed O, Ornstein E, Connolly ES, Heyer EJ. Takotsubo cardiomyopathy associated with anesthesia: three case reports. Cases J. 2008;1(1):227. Published 2008 Oct 8. doi:10.1186/1757-1626-1-227 Reference #3: Gili S, Cammann VL, Schlossbauer SA, et al. Cardiac arrest in takotsubo syndrome: results from the InterTAK Registry. Eur Heart J. 2019;40(26):2142–2151. doi:10.1093/eurheartj/ehz170 DISCLOSURES: No relevant relationships by Joseph Baum, source=Web Response no disclosure on file for Brian Bauman; No relevant relationships by William Bauman, source=Web Response No relevant relationships by Vishal Dahya, source=Web Response No relevant relationships by Rahul Dasgupta, source=Web Response No relevant relationships by Julia Lantry, source=Web Response