VENTRICULAR TACHYCARDIA ELECTRICAL STORM AS A MANIFESTATION OF REVERSE VARIANT TAKOTSUBO CARDIOMYOPATHY

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TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Takotsubo cardiomyopathy (TTC) is a syndrome with transient systolic dysfunction in the absence of obstructive coronary arteries with the reverse variant being a rare entity (1,2). Here, we report a case of reverse TTC presenting with monomorphic ventricular tachycardia (VT) electrical storm. CASE PRESENTATION: A 76 year-old female with a history of recently diagnosed Stage IIIB lung adenocarcinoma presented to the emergency room with shortness of breath. On presentation, her vitals were: BP 134/82, pulse 120 beats/min, SPO2 93% in room air. Initial EKG showed no significant ST-T wave changes and normal QTc. Labs were significant for uptrending troponin from 0.8 to 4 ng/mL. Aspirin and heparin infusion were started for possible NSTEMI with a plan for catheterization. That night, she developed unstable, monomorphic VT (Figure 1). Consecutive synchronized cardioversions and amiodarone boluses were unsuccessful. Patient's VT terminated with repeated boluses of lidocaine followed by lidocaine infusion. Stat echocardiogram showed an ejection fraction of 25-30% with anterior and anteroseptal hypokinesis. Emergency cardiac catheterization revealed non-obstructive coronary arteries with akinesis of the basal wall and sparing of the apex suggesting reverse TTC (Figure 2). She was transferred to the critical care unit where she was transitioned to amiodarone infusion with no further VT episodes and was initiated on guideline-directed medical therapy. DISCUSSION: TTC usually occurs due to a surge of catecholamines leading to myocardial damage. The typical variant demonstrates apical ballooning with basal hypokinesis. Rarely, there may be basal hypokinesis with apical sparing, the reverse variant (2). Arrhythmias are uncommon in typical TTC and prior studies have indicated a low incidence of VT (3.2%) (3). There is sparse literature describing the incidence of VT or VT storm in the reverse variant. One of the postulated mechanisms for VT in TTC is transient QTc prolongation, however this remains controversial. (3). The incidence of arrhythmias is thought to be more prevalent during the acute phase leading to increased in-hospital mortality (3). Additionally, it remains uncertain whether prophylactic antiarrhythmics are beneficial in this population subset. Further studies are warranted to understand which variants of TTC develop critical arrhythmias. CONCLUSIONS: Reverse variant is a rare subset of TTC which can present with critical arrhythmias including VT storm. Awareness of this manifestation can help clinicians with early recognition and management of these critical arrhythmias. REFERENCE #1: Bybee KA., Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118(4):397–409. Doi: 10.1161/CIRCULATIONAHA.106.677625. REFERENCE #2: Templin C., Ghadri JR., Diekmann J., et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. New England Journal of Medicine 2015;373(10):929–38. Doi: 10.1056/NEJMoa1406761. REFERENCE #3: Pant S, Deshmukh A, Mehta K, et al. Burden of arrhythmias in patients with Takotsubo Cardiomyopathy (Apical Ballooning Syndrome). International Journal of Cardiology [Internet] 2013;170(1):64–68. Available from: https://doi.org/10.1016/j.ijcard.2013.10.041 DISCLOSURES: No relevant relationships by Anneka Hutton, source=Web Response No relevant relationships by Gagan Neupane, source=Web Response No relevant relationships by Enoemem Okpokpo, source=Web Response No relevant relationships by Bharadwaj Satyavolu, source=Web Response No relevant relationships by Raksha Sharma, source=Web Response No relevant relationships by Tracey Topacio, source=Web Response