Catecholamine-induced Takotsubo syndrome: a case series

Abstract

Background: Catecholamine-induced Takotsubo Syndrome (cat-TS) is a type of secondary Takotsubo syndrome, characterized by rapid onset of symptoms, high rate of complications during the acute phase, good short-term prognosis, and frequent apical sparing at echocardiogram. We present two clinical cases of cat-TS treated in our department.

Case summary: Case one: 78-year-old man, admitted to Ear Nose and Throat Unit for surgical removal of oral squamous cellular carcinoma. During surgery, the occurrence of hypotensive episode was treated with catecholamines. After surgery, the occurrence of atrial fibrillation was followed by evidence of phasic increase of troponin levels and akinesia of midventricular segments. Angiography showed the absence of significant coronary stenoses, and during hospital stay, we observed rapid recovery of wall motion abnormalities. Case two: 64-year-old woman, admitted for hysteropexy surgery, during which cardiac arrest occurred, treated with epinephrine i.v.1 mg and DC shock. Two hours after resuscitation, the patient developed pulmonary oedema, troponin levels increased progressively, and the echocardiogram demonstrated hypokinesia in all midventricular segments with apical sparing. Afterwards, an urgent angiography highlighted normal coronary anatomy. Cardiac magnetic resonance imaging (MRI) revealed oedema corresponding to hypokinetic areas. On the seventh day, echocardiogram showed a complete remission of wall motion abnormalities.

Discussion: These cases warn the physicians about the importance of routinely screening myocardial impairment through clinical assessment, electrocardiogram (ECG) monitoring, and serial cardiac troponin testing after catecholamine i.v. bolus administration. In case of alterations of these exams, performing a prompt echocardiogram allows early detection of cat-TS, to provide immediate suitable medical support and avoid complications.

Keywords: Case series; Catecholamines; Echocardiography; Takotsubo syndrome.

Figure 1

Transthoracic echocardiogram highlighting midventricular segments akinesia with apical compensatory hyperkinesia.

Figure 2

The ECG showed SR, HR 75/min, and hyperacute T-waves from V3 to V5.

Figure 3

ECG showing inverted T-waves from V1 to V6 leads, corrected QT interval according to Bazzett’s formula of 566 ms.

Figure 4

MRI T2 stir sequences showing hyperintensity of signal at midventricular and apical segments.

Figure 5

Prolongation of relaxation times in MRI T2 mapping sequences, compatible with oedema.