Presentations

Abstract

Introduction:

Takotsubo cardiomyopathy (TC) is a well-described, transient condition that commonly affects elderly women after a stressful emotional or physical trigger. Presenting features often include: severe chest pain, ECG abnormalities mimicking acute myocardial infarction, and transient left ventricular wall motion abnormalities (including apical ballooning, from which the condition's namesake arises). Severe manifestations of TC can include cardiogenic shock of patients, with a sharp increase in rate of mortality [3].

Case Information:

A 66-year-old female with no significant cardiac history presented to an emergency department for evaluation of two hours of chest pain, attributed to stress about moving in with her daughter. Her ECG met STEMI criteria, prompting emergent left heart catheterization (LHC) which demonstrated normal coronaries. She was initiated on milrinone and levophed infusions for cardiogenic shock. Initial echocardiography demonstrated reduced systolic function (LVEF 20%), a strain pattern consistent with Takotsubo cardiomyopathy (apical ballooning), severe mitral valve regurgitation (MVR) with posterior leaflet systolic anterior motion (SAM), and pulmonary hypertension (sPAP 45). Subsequent right heart catheterization demonstrated reduced CI (TD 1.66) with elevated SVR (>1600 cgs), prompting the decision to place a left ventricular assist device (LVAD). During peri-procedural LHC, significant pressure drop on pullback from the LV to aorta confirmed a severe dynamic left ventricular outflow track obstruction (LVOTO). LVAD placement was then aborted. Given her complex, multifactorial shock (TC, SAM w/ LVOTO, & MVR), the patient was transferred to a regional tertiary shock center. The accepting advanced heart failure team discontinued milrinone and levophed, in favor of continuous esmolol, lasix, and vasopressin infusions. Structural heart and cardiothoracic surgery teams considered options for interventional management, ultimately deciding to pursue urgent percutaneous Mitra-clip placement. Repeat echocardiography showed trace residual MVR with resolution of LVOTO, leading to rapid improvement in hemodynamic status. She was able to be weaned off all supportive infusions within 48 hours after Mitra-clip placement. She was initiated on goal directed medical therapy and discharged a few days later. Serial echocardiograms showed full recovery of systolic function.

Discussion:

The associated features of LVOTO and severe MVR represents a very rare presentation of TC, previously described in only a few scattered case reports [2]. The contraction pattern of typical TC, namely apical ballooning with basilar hyperkinesis, is thought to induce narrowing of the LVOT. In this case, the MVR involved SAM, which exacerbated the already narrowed channel, producing a dynamic LVOTO. For MVR, afterload reduction improves cardiac output, but for LVOTO, increased afterload helps prevent LVOT collapse. Because of these opposing goals, standard management of cardiogenic shock (pressors and inotropes) can paradoxically worsen hemodynamic status, as it did in this patient [2]. Consideration of this complex hemodynamic interplay led to pursuit of mitral valve repair. This key intervention reduced the severity of the MVR and resolved the LVOTO by anchoring the posterior mitral leaflet, eliminating the SAM.

Conclusion:

This case highlights a rare presentation of TC, in which a complex association of SAM, LVOTO, and MVR produced a multifaceted cardiogenic shock. Mitra-clip placement resolved the confounding hemodynamic picture and led to rapid clinical improvement.