TAKOTSUBO CARDIOMYOPATHY AS AN ADVERSE EVENT POST BRONCHOSCOPY

Abstract

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Takotsubo cardiomyopathy (TTC) is an acute cardiac syndrome characterized by acute dilated cardiomyopathy following emotional or physical stress. It presents with sudden onset of cardiac symptoms with electrocardiogram(ECG) changes and left ventricular dysfunction. Echocardiogram findings are characteristic of apical ballooning with a wide base and long thin neck at end-diastole. The prevalence of TTC in patients with known vasculitis is not well described. CASE PRESENTATION: Our patient is a 46 Chinese lady with known history of migraine and anxiety. She first presented with non-resolving oto-mastoditis despite multiple courses of antibiotics. She subsequently developed bilateral cavitary lung lesions for which a bronchoscopy was performed. The work-up was negative for microbiology including mycobacterium and fungal organisms. Her antiPR3 antibodies were markedly raised and a diagnosis of Granulomatosis with Polyangiitis (GPA) was made. She was treated with intravenous pulsed steroids and cyclophosphamide. However, she developed fever and cough with worsening of bilateral cavitary lung lesions and neutrophilia. Bronchoscopy and transbronchial lung biopsy were repeated in view of concerns of infection in a immunocompromised host. 2 hours post procedure, she developed sinus tachycardia and type 1 respiratory failure requiring intubation and mechanical ventilation. Cardiac enzymes trended were not suggestive of myocarditis or acute myocardial infarct. ECG showed new T-wave inversions in the anterior leads. A bedside echocardiogram showed dilated cardiomyopathy with an ejection fraction(EF) of 10-15%. She was subsequently extubated and a repeat echocardiogram confirmed the characteristic findings of TTC with apical ballooning and akinesia and improvement in EF to 30-35%. DISCUSSION: One of the proposed pathophysiology behind TTC is the abnormally high levels of catecholamines resulting in catecholamine-associated cardiotoxicity post physical or emotional stressors. Previous papers have described TTC post bronchoscopy to be more common in post-menopausal women, history of asthma; and in more invasive procedures such as transbronchial lung biopsies and adrenaline administration intra-tracheally; therefore benefit-risk ratio for adrenaline administration needs to be considered in patients at risk. Treatment is usually supportive with treatment of heart failure and reassurance. CONCLUSIONS: TTC post bronchoscopy is an uncommon but life threatening adverse event. This case highlights the need to identify patients who are at risk of developing TTC post bronchoscopy and ensure preventive measures such as adequate counselling are carried out pre-procedure. The diagnosis of TTC should be suspected in high risk patients with cardiac symptoms and close monitoring post procedure should also be implemented as the complications of TTC can be severe and life threatening as demonstrated in our patient. Reference #1: Nyquist KE, Abramson DW, Huffman JC. Apical ballooning syndrome: the "broken heart" syndrome. Prim Care Companion J Clin Psychiatry. 2010;12(5):PCC.10r00949. Reference #2: Four cases of clinical analysis with Takotsubo cardiomyopathy associated with bronchoscopy: Manabu Suzuki et al. European Respiratory Journal 2017 50: PA3803; https://doi.org/10.1183/1393003.congress-2017.PA3803 Reference #3: Takotsubo Cardiomyopathy and Subsequent Seizures Induced by Flexible Bronchoscopy Shion Miyoshi MD, Yuichiro Takeda MD PhD, Shoki Ro MD, Haruna Masaki MD, Masayuki Hojo MD, and Haruhito Sugiyama MD PhD. DISCLOSURES: No relevant relationships by Adrian Kwok Wai Chan, source=Web Response No relevant relationships by Sandra HUI, source=Web Response No relevant relationships by Keng Leong TAN, source=Web Response