["Takotsubo" cardiomyopathy with pneumothorax]

Takotsubo syndrome following radiofrequency ablation of atrial fibrillation in a patient with coronary artery anomaly: a case report

Background

Takotsubo syndrome (TTS) is an acute heart failure syndrome usually induced by emotional or physical stress. The prevalence of TTS seems to be higher than previously anticipated. Radiofrequency catheter ablation could be a rare trigger of TTS. The pathophysiology is not fully understood. Sympathetic stimulation plays an important role on the development of TTS.

Case summary

A 62-year-old woman was referred for RFCA because of drug-refractory symptomatic paroxysmal atrial fibrillation. No other chronic diseases were stated except for a hypertension history. Three hours after the AF ablation, the patient complained of chest pain. New electrocardiographic abnormalities were presented including progressive T-wave inversion and significant QT prolongation. Multimodality imaging, including echocardiography, coronary angiography, left ventriculography, and computed tomography was conducted in establishing the TTS diagnosis. The congenital coronary artery anomaly was confirmed at the same time. Both transthoracic echocardiography and left ventriculography showed typical TTS changes. Elevation of the brain natriuretic peptide and Troponin I was observed during the acute phase. Angiotensin-converting enzyme inhibitor and β-blocker were administrated during hospitalization and after discharge. Two weeks later, echocardiography and cardiovascular magnetic resonance revealed a total recovery of left ventricular function and apex kinesis.

Discussion

Sometimes, it is hard to distinguish TTS from acute coronary syndrome because of similar manifestations. Multimodality imaging is helpful to confirm the diagnosis. Radiofrequency catheter ablation could be a rare trigger of TTS, and its incidence may increase in patients with coronary artery anomaly. Coronary spasm and increased cardiac sympathetic activity induced by the ablation might be the mechanism involved.

Tension pneumothorax-induced Takotsubo syndrome: A case report

RATIONALE

Takotsubo syndrome (TTS) is a form of acute and usually reversible heart failure syndrome. Transient left ventricular dysfunction and electrocardiographic changes could mimic acute coronary syndrome but there are actually no obstructive coronary lesions.

PATIENT CONCERNS

A 76-year-old woman with chronic lung disease developed spontaneous tension pneumothorax with the presentation of severe dyspnea, respiratory failure, left ventricular dysfunction, and anterior wall ST-segment elevation on 12-lead electrocardiogram. Acute coronary syndrome was excluded by normal coronary angiograms.

DIAGNOSIS

The patient was diagnosed as tension pneumothorax complicated by TTS.

INTERVENTIONS

The woman underwent tubal thoracostomy for tension pneumothorax-induced obstructive shock. However, the patient further underwent ligation bullectomy for persistent air leakage 2 weeks later.

OUTCOMES

The left ventricular dysfunction recovered 1 week after resolution of tension pneumothorax. Anterior wall ST-segment elevation resolved 25 days after admission.

LESSONS

Concurrent electrocardiograms and echocardiographic serial evaluations should be performed to provide more comprehensive information when dealing with tension pneumothorax patients.

Takotsubo Syndrome - Stress-induced Heart Failure Syndrome

Takotsubo syndrome has been established as an entity in the past 30 years, particularly with the introduction of interventional angiography for investigation of chest pain. Typically, it occurs in middle-aged females as a response to a stressful event, such as bad news, death, accident, natural disaster, etc. but there is not always a specific trigger. Takotsubo mimics acute myocardial infarction with electrocardiogram changes and elevated troponins. On interventional angiography the coronary arteries are normal with typical apical ballooning of the left ventricle. This feature led to its descriptive name, given by Japanese cardiologists, as the left ventricle resembles a lobster trap with a narrow neck extending into a round ventricle. This leads to a reduction in cardiac function. Takotsubo is believed to be a response to catecholamine release following a stressful event resulting in temporary myocardial damage. It usually has a benign course with spontaneous return of cardiac function. However it may recur and in a small percentage of patients can result in sudden cardiac death with arrhythmia, acute myocardial infarction and cardiac rupture. It is usually treated symptomatically depending on the severity of presentation.