Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction and Shock

Abstract

SESSION TITLE: Heart Failure and Cardiogenic Shock SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Takotsubo cardiomyopathy (TCM), also known as apical ballooning syndrome, mimics acute coronary syndrome. We report a unique case of a female who presented as STEMI with hypotension, and was found to have TCM causing significant Left ventricular outflow tract (LVOT) obstruction. CASE PRESENTATION: A 70-year-old female with history of hypertension, hyperlipidemia presented to our ER with exertional shortness of breath and chest pain. She denied any recent stress. She was hypotensive with BP of 80/43 mmHg and had bibasilar pulmonary rales. Lab showed BNP of 1673 pg/ml and positive cardiac troponins which increased from 3.76 to 4.25 ng/ml. Chest X-ray revealed pulmonary vascular congestion. EKG showed ST-elevation in anterior leads. ECHO showed EF of 35% with akinetic LV apex and dynamic LV outflow tract obstruction with peak velocity of approximately 4 m/s. Patient underwent cardiac catheterization that showed clean coronaries. Left ventriculogram showed basal hypokinesis with apical ballooning during systole (Figure 1). The above findings along with ST-elevation on EKG were consistent with TCM. Thus, the diagnosis of TCM with LVOT obstruction was established. She was medically managed with beta-blockers. Repeat ECHO performed 5-days later showed complete recovery of LV systolic function with resolution of apical ballooning. She was later discharged home in a stable condition and she continued to do well at 3-month follow up. DISCUSSION: TCM is known to cause transient systolic LV dysfunction and ST-T changes on ECG following various triggering factors. Our case is an example of a rare presentation of TCM causing LVOT obstruction and hypotension initially mimicking STEMI. A review of literature suggests that only 10-20% of patients with TCM develop cardiogenic shock. Hypotension may develop in patients with TCM due to multiple mechanisms such as left ventricular systolic dysfunction, significant mitral regurgitation secondary to systolic anterior motion of the mitral valve, dynamic LVOT obstruction, or a combination of these factors (1). As the management of cardiogenic shock due to LVOT obstruction is very different from other causes of cardiogenic shock, all patients with suspected TCM causing shock should first undergo ECHO to rule out LVOT obstruction. Inotropic agents and intraaortic balloon pump (IABP) used for the treatment of cardiogenic shock due to STEMI can paradoxically increase LVOT pressure gradients and worsen the dynamic gradient in patients with TCM and LVOT obstruction (1). This can lead to worsening of shock and catastrophic sequelae. CONCLUSIONS: In patients with hypotension and ECHO suggestive of TCM, LVOT obstruction must be ruled out. Inotropic agents and IABP are relatively contraindicated in cardiogenic shock due to LVOT obstruction. Thus, timely diagnosis and appropriate management of TCM with LVOT obstruction is imperative. Reference #1: Shah BN, et al. JACC Sep 2011;58(11);1195-1196. DOI:10.1016/j.jacc.2011.03.062 DISCLOSURE: The following authors have nothing to disclose: Parita Soni, Sameer Chadha, Nidhi Aggarwal, Anand Kumar Rai, Yizhak Kupfer, Bilal Mailk No Product/Research Disclosure Information