A life-threatening reverse Takotsubo syndrome in a young breastfeeding woman: a case report

Abstract

Background: Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction and is usually triggered by emotional, physical, or combined stress. This syndrome has been increasingly recognized, although it remains a challenging and often misdiagnosed disorder.

Case summary: A 36-year-old breastfeeding woman was admitted with sudden dyspnoea and oppressive chest pain. On admission, she was lethargic, hypotensive, and tachycardic. The electrocardiogram showed rapid atrial fibrillation and diffuse ST-segment depression. The transthoracic echocardiogram (TTE) revealed severe LV systolic dysfunction, with midventricular and basal akinesis, compensatory apical hyperkinesia, and without intraventricular gradient. Emergent coronary angiogram showed normal coronary arteries. A presumptive diagnosis of reverse TTS with cardiogenic shock (CS) was made. The patient was transferred to the intensive care unit after intubation and inotropic and vasopressor support was initiated. During hospitalization, rapid clinical improvement was observed. In 3 days, the patient was weaned from haemodynamic support and extubated. Furthermore, β-blocker and angiotensin receptor blocker were initiated and tolerated. Cabergoline was also administered to inhibit lactation. The presumptive diagnosis was further strengthened by cardiac magnetic resonance and all triggering factors were excluded. At hospital discharge she was asymptomatic and the follow-up TTE was normal, which confirmed the diagnosis of reverse TTS.

Discussion: We present a case of a young woman, 8 months after delivery, which developed a life-threatening reverse TTS without triggering factor identified. Reverse TTS is a rare variant of TTS with different clinical features and is more likely to be complicated by pulmonary oedema and CS.

Keywords: Breastfeeding; Cardiogenic shock; Case report; Reverse Takotsubo syndrome.

Figure 1

Admission electrocardiogram.

Figure 7

Figure 2

Cardiac magnetic resonance showed no late gadolinium enhancement.

Figure 3

Cardiac magnetic resonance showed light oedema in basal and midventricular segments.

Figure 4

Electrocardiogram during hospitalization.

Figure 5

Follow-up electrocardiogram.

Figure 6

Diagnostic algorithm. cMR, cardiac magnetic resonance; ECG, electrocardiogram; LV, left ventricular; TTE, transthoracic echocardiogram; TTS, Takotsubo syndrome.