Inverted stress- induced cardiomyopathy as a unusual variant of acute heart failure after cesarean delivery- a case report

Abstract

Background: Stress- induced cardiomyopathy is acute, reversible left ventricle mainly apical dysfunction in patients with normal coronary angiography. Rarely it regards basal segments, therefore defined as "inverted stress- induced cardiomyopathy". While classic form mostly affects postmenopausal women, inverted variant occurs essentially in younger females, always triggered by stress. It can also develop after medical procedures and surgery. Herein we report such unique case of 36- year old woman after cesarean delivery.

Case presentation: A 36- year- old white woman at 40 week of gestation was admitted to hospital for elective repeated cesarean delivery. During caesarean delivery under spinal anaesthesia a previously healthy woman became hypotensive, requiring ephedrine to maintain her blood pressure. Three hours after delivery the patient presented acute heart failure and pulmonary oedema. Due to low blood pressure she demanded the administration of inotropic agents. Owing to respiratory failure and gradual deterioration of consciousness, mechanical ventilation was applied. Results of additional tests finally excluded pulmonary thromboembolism and acute coronary syndrome. The transthoracic echocardiography revealed severe left ventricular systolic dysfunction, ejection fraction 30 % with hypokinesis of the mid and basal segments of posterior, anterior and lateral wall with preserved contractility of the apical segments. The diagnosis of inverted stress- induced cardiomyopathy was set upon the overall clinical data. Both echocardiography and magnetic resonance imaging performed on the fifth day showed complete recovery of myocardial function. The patient was discharged after 15 days in good overall condition. At 12- month follow- up she remained asymptomatic with no echocardiographic abnormalities.

Conclusions: Inverted stress- induced cardiomyopathy may occur in postpartum period, especially in combination with spinal anesthesia and adrenergic stimulants administration. The clinical awareness and multimodality imaging of possible diagnosis and further management of this unexpected variant of acute heart failure after caesarean delivery is required.

Keywords: Acute heart failure; Cesarean delivery; Inverted stress- induced cardiomyopathy.

Fig. 1

Chest computed tomography demonstrating severe pulmonary oedema

Fig. 2

Electrocardiogram

Fig. 3

Cardiac magnetic resonance imaging with late gadolinium enhancement in four chamber view, without evidence of tissue abnormalities (scars, patchy fibrosis)

Fig. 4

Short-axis, dark- blood T2- weighted cardiac magnetic resonance imaging demonstrating no signs of myocardial edema