Takotsubo syndrome in a patient after renal transplantation

Abstract

Background: Takotsubo syndrome (TTS) is a transient cardiomyopathy of unknown origin, clinically manifesting as acute coronary syndrome (ACS). This syndrome mainly occurs in postmenopausal women and has a temporary relationship with emotional or physical stress.

Case report: TTS occurred in 46-year-old female patient on the first day after renal transplantation. The predominant symptoms were connected with ACS, performed with low grade troponin elevation and characteristic shape of left ventricle depicted in echocardiography. Taking into consideration the risk of the development of contrast-induced nephropathy, coronary angiography (CA) was delayed; myocardial perfusion scintigraphy and iodine-123 metaiodobenzylguanidine (¹²³I-mIBG) myocardial uptake were performed to confirm the clinical suspicion. Myocardial perfusion scintigraphy (MPS) performed in rest condition showed normal perfusion but myocardial uptake of ¹²³I-mIBG was impaired. Within 6 months after surgery, full recovery of all biochemical and functional parameters of the left ventricle were observed. At that time CA was done, depicting normal coronary arteries.

Conclusions: TTS could be diagnosed by the use of non-nephrotoxic tests - ¹²³I-mIBG myocardial scintigraphy, MPS and echocardiography.

Figure 1

ECG performed on the onset of TTS.

Figure 2

(A) Transthoracic echocardiography, the four-chamber projection: LV – left ventricle, LA – left atrium, RV – right ventricle, RA – right atrium. First day after renal transplantation, the phase of diastole. (B) Transthoracic echocardiography, the four-chamber projection: LV – left ventricle, LA – left atrium, RV – right ventricle, RA – right atrium. First day after renal transplantation, the phase of systole: left ventricular apical akinesis, preserved systolic function, and basal segments of the middle part LV.

Figure 3

(A) Transthoracic echocardiography, the four-chamber projection: LV – left ventricle, LA – left atrium, RV – right ventricle, RA – right atrium. 6 months after renal transplantation, the phase of diastole. (B) Transthoracic echocardiography, the four-chamber projection: LV – left ventricle, LA – left atrium, RV – right ventricle, RA – right atrium. 6 months after renal transplantation, the phase of systole – normal function of LV.

Figure 4

The normalization of ECG after 6 months.

Figure 5

A comparison of SPECT coronal slices from myocardial perfusion studies ((A) – in acute phase of TTS and (D) – in the recovery) and from ¹²³I-mIBG myocardial scintigraphy (in acute phase (B) – 15 minutes and, (C) – 4 hours post-injection of radiotracer; and after normalization (E) –15 minutes and (F) – 4 hours post-injection of ¹²³I-mIBG)