THIS TOO SHALL PASS (UNTIL IT DOESN'T): A RARE CASE OF TAKOTSUBO CARDIOMYOPATHY WITH PERSISTENT LEFT VENTRICULAR DYSFUNCTION

Abstract

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Takotsubo cardiomyopathy (TCM) is characterized by acute regional dysfunction of the left ventricle (LV) triggered by emotional or physical stress. There is an absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. TCM is usually reversible within a few weeks to months. Here, we present a rare case of TCM in which 6 months post inciting event there was not only a lack in recovery of LV function, but also new onset ventricular arrhythmias requiring AICD placement. CASE PRESENTATION: A 72-year-old male with a past medical history of hypertension, hyperlipidemia, and diabetes, presented with substernal chest pain for the last 10 days. The patient also reported increased work-related stress recently. EKG showed diffuse ST segment elevations and T wave inversions. Transthoracic echocardiogram (TTE) demonstrated a severely hypokinetic LV apical segment with a left ventricular ejection fraction (LVEF) of 45%. There was no significant atherosclerotic occlusion on coronary angiography. On follow up visit 4 months later, EKG showed persistent diffuse Q waves in anteroseptal and inferior leads with resolution of T wave inversions. The patient also developed new-onset paroxysmal atrial fibrillation. 6 months later, the patient presented with a complaint of palpitations, dizziness, and lethargy. TTE at that time showed persistent diminished LVEF to 45% with continued LV apical hypokinesis. The patient underwent an electrophysiology study that showed new-onset inducible ventricular tachycardia and lengthy sinus nodal reentrant tachycardia. He underwent successful left subclavian dual-lead AICD placement, with resolution of symptoms. DISCUSSION: TCM is generally characterized as transient LV dysfunction secondary to a stressor, with regression of wall motion abnormalities and gradual restoration of LVEF until complete recovery is achieved. Here, we describe a unique case, in which more than 6 months after the inciting event, LV function was still impaired. In approximately 20% of cases of TCM, complications may occur, including cardiogenic shock, heart failure, rhythm disorders, LV thrombus formation, free wall rupture, and death. There have been very few cases, as in this case, in which not only did LV function not recover but rhythm disorders developed months after the inciting event. Differences in the evolution of TCM may be attributed to the different pathophysiological mechanisms that have been cited to contribute to the disorder – namely, catecholamine-induced myocardial stunning, transient epicardial vasospasm, coronary microvascular dysfunction, and transient LV obstructions. CONCLUSIONS: TCM is often characterized as transient LV dysfunction. This case demonstrated the need for close monitoring post inciting event, as there is a possibility for persistent LVEF depression, as well as further complications that could significantly increase mortality. Reference #1: Virani, S. S., Khan, A. N., Mendoza, C. E., Ferreira, A. C., & de Marchena, E. (2007). Takotsubo cardiomyopathy, or broken-heart syndrome. Texas Heart Institute journal, 34(1), 76-9. Reference #2: Zalewska-Adamiec, M., Bachorzewska-Gajewska, H., Tomaszuk-Kazberuk, A., Nowak, K., Drozdowski, P., Bychowski, J., Krynicki, R., Musial, W. J., … Dobrzycki, S. (2016). Takotsubo cardiomyopathy: serious early complications and two-year mortality - a 101 case study. Netherlands heart journal : monthly journal of the Netherlands Society of Cardiology and the Netherlands Heart Foundation, 24(9), 511-9. DISCLOSURES: no disclosure on file for Rakesh Gupta; No relevant relationships by Christina Jee Ah Rhee, source=Web Response No relevant relationships by Sharmila Sarkar, source=Web Response