Takotsubo syndrome induced by brachytherapy in a patient with endocervical adenocarcinoma

Abstract

Background: Takotsubo syndrome (TTS), also known as stress cardiomyopathy, apical ballooning syndrome and broken heart syndrome, is characterized by acute-onset chest pain, electrocardiographic (ECG) abnormalities and reversible left ventricular (LV) disfunction in the absence of a culprit obstructive lesion in the coronary arteries; therefore, myocardial infarction is the most important differential diagnosis. Usually induced by emotional/physical stress, its treatment consists in hemodynamic support until complete and spontaneous recovery occurs, which is generally achieved within a few days to weeks. Cervical malignancies are an important public health issue in low/middle-income countries and, in the setting of locally advanced disease, concurrent chemoradiation followed by brachytherapy is considered the standard treatment, harboring curative potential.

Case report: We report a case of a 38-year-old woman who underwent concurrent chemoradiotherapy and developed cardiopulmonary arrest in ventricular fibrillation during a brachytherapy session. Complementary tests disclosed altered ECG and cardiac biomarkers, no evidence of coronary artery obstruction, as well as LV disfunction consistent with TTS on echocardiogram and cardiac MRI. After few days of supportive therapy, complete recovery of heart function was observed.

Conclusions: Especially for cancer patients, who usually experience intense emotional/physical stress intrinsically associated with their diagnosis and aggressive treatments, considering TTS as a differential diagnosis is warranted. Intracavitary brachytherapy procedure may represent a trigger for TTS.

Keywords: Brachytherapy; Broken heart syndrome; Endocervical adenocarcinoma; Heart failure; Stress cardiomyopathy; Takotsubo.

Fig. 1

Apical 4 chambers view showing akinesia of the mid-apical segments of the inferior septal and anterolateral walls, determining apical ballooning (arrows). LA: Left Atrial. LV: Left Ventricle. RA: Right Atrial. RV: Right Ventricle

Fig. 2

Cineangiocoronariography showing absent of significant obstructive atherosclerotic lesions. Left coronary in right anterior cranial oblique incidence (a). Right coronary in left anterior cranial oblique incidence (b). Cardiac ventriculography demonstrating mid left ventricular segments hypokinesia (arrows). Left ventricle in max diastole (c) and in max systole (d) in right oblique incidence.

Fig. 3

Cine cardiac magnetic resonance images showing a 3-chamber view of the left ventricle in end diastole (a) and in end systole (b) demonstrating a circumferential mid-ventricle hypokinesia with greater intensity in the anteroseptal segment (arrows). (c) image shows late gadolinium enhancement sequence showing a 4-chamber view of the heart without any sign of myocardial fibrosis. (d) Cine cardiac magnetic resonance sequence demonstrating diffuse pericardium effusion of moderate intensity (arrows). (e) Short-tau inversion-recovery (STIR) sequence, a T2-weighted sequence used to assess myocardial edema, demonstrating the presence of hypersignal in the middle segments of the anterior, septal and lateral walls (arrows) which indicates the presence of myocardial edema in these segments