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Inverse takotsubo cardiomyopathy in the peripartum period
Abstract Number: F-36
Abstract Type: Case Report/Case Series
Takotsubo cardiomyopathy (TCM), also known as broken heart syndrome, is a stress induced cardiomyopathy, thought to be caused by excessive catecholamine release due to acute medical illness or emotional or physical stress. The word takotsubo is a Japanese word meaning “octopus pot,” which is used to trap an octopus. This pot resembles the shape of the left ventricle during imaging which shows apical ballooning, left ventricular akinesia or hypokinesia combined with basal hypercontractility. Inverse TCM is a variant of TCM with similar pathophysiology but with different presenting symptoms and reverse features on imaging i.e. basal hypokinesia. TCM and its inverse variant were first reported in the Japanese literature and its awareness in the Western population is more recent.
A 29-year-old Turkish lady presented for an emergency lower segment caesarean section (LSCS) which was conducted under spinal anaesthesia. During the LSCS and in the immediate postoperative period she complained of chest pain. There was no clinical evidence of pulmonary edema. Upon investigation, she was found to have ECG changes suggestive of non-ST elevation myocardial infarction with positive results for troponin I. Hence, she was initially treated as a case of acute coronary syndrome. However, a subsequent coronary angiogram showed no obstruction or spasm of the coronary arteries while an echocardiogram showed a left ventricular ejection fraction of <25% with basal hypokinesia. Further evaluation with cardiac magnetic resonance imaging, with gadolinium, showed a delayed myocardial uptake of gadolinium with hypokinesia of the basal segments. Hence, a diagnosis of inverse TCM was made and the patient was treated appropriately.
TCM is treated with aspirin, β-blockers, angiotensin converting enzyme inhibitors and diuretics, with recovery of left ventricular function typically occurring in 2-4 weeks. As TCM is caused by catecholamine overload, the use of inotropes and vasopressors can cause haemodynamic instability. The aim of reporting this case was to raise awareness of TCM and its inverse variant in the general population and in the obstetric population in particular.
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2. Crimi E, Baggish A, Leffert L, Pian-Smith M, Januzzi J, Jian Y. Acute reversible stress-induced cardiomyopathy with cesarean delivery under spinal anesthesia. Circulation. 2008;117:3052–3053.
3. Song BG, Chun WJ, Park YH, Kang GH, Oh J, Lee SC, Park SW, Oh JK: The clinical characteristics, laboratory parameters, electrocardiographic, and echocardiographic findings of reverse or inverted takotsubo cardiomyopathy: comparison with mid or apical variant. Clin Cardiol 2011, 34:693-699