Quadruple episodes of takotsubo cardiomyopathy: a case report

Abstract

Background: Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction, often preceded by emotional or physical trigger. The recurrence of TTS has been investigated, however, cases of multiple recurrences are scarcely reported.

Case summary: A 79-year-old woman was admitted to the hospital with the complaint of dyspnoea following emotional stress. Electrocardiogram showed terminal T-wave inversion with QT interval prolongation in anterior leads. Transthoracic echocardiogram revealed severe hypokinesis of mid- and apical-anterior segments. She was diagnosed with focal TTS. After 3 months, she complained of orthopnoea subsequent to upper-respiratory infection. Coronary angiography (CAG) depicted normal coronary arteries. She had recurrence of TTS with bi-ventricular dysfunction, and complicated cardiac collapse requiring intra-aortic balloon pumping. One month after the second episode, she had dyspnoea after herpes zoster infection. She was diagnosed with recurrence of focal TTS. After 4 months, she complained of central chest pain without evident trigger factors. CAG showed no coronary artery stenosis, and left ventriculography revealed mid-inferior and apical segment akinesis. She was diagnosed with the 4th occurrence of TTS.

Discussion: We describe the case of an elderly female experiencing quadruple episodes of TTS with various triggers, LV dysfunctions and severities in a short period of 10 months. Although multiple recurrences of TTS is rare, it can occur with variable trigger factors and patterns of myocardial dysfunction. An analysis of multiple recurrences could aid in clarifying the pathophysiology of TTS.

Keywords: Case report; Multiple; Recurrence; Stress induced cardiomyopathy; Takotsubo syndrome.

Figure 1

Electrocardiogram. Electrocardiogram of the patient with quadruple takotsubo syndrome.

Figure 2

Transthoracic echocardiography and coronary angiography. Transthoracic echocardiography of the patient during the second and third episode of takotsubo syndrome (dashed lines: hypokinesis or akinesis); no occlusive coronary arteries were found during the second episode.

Figure 3

Dual single-photon emission computed tomography. Upper panels: ^99mTc-tetrofosmin accumulates the whole regions of left ventricle. Lower panels: ¹²³I-beta-methyl iodophenyl-pentadecanoic acid defects in the apical-anterior and mid to apical inferoseptum segments (asterisks).