Pregnancy-Associated Takotsubo Syndrome: A Narrative Review of the Literature

Abstract

Takotsubo syndrome (TTS) is a clinical syndrome defined most typically by transient systolic dysfunction and dilatation of the apex of the left ventricle or other regional areas in the documented absence of obstructive coronary artery disease. Although more commonly presented in postmenopausal women, there are reports in the literature of TTS during the peripartum and postpartum periods. Early TTS diagnosis in pregnancy is of great importance in improving both maternal and fetal mortality. Although TTS involves many pathogenetic pathways, the imbalance between declining estrogen and arising sympathetic nervous system tone plays an important role. This review aims to provide recent published evidence of TTS in pregnancy and delve into the epidemiology of TTS in pregnancy, the pathophysiological mechanisms involved, the prognosis of TTS for the mother and the fetus, and its therapeutic multi-disciplinary management.

Keywords: coronary syndrome; peripartum; peripartum cardiomyopathy; pregnancy; takotsubo syndrome.

Figure 1

Cardiovascular changes during pregnancy. HR: heart rate, LVH: left ventricular hypertrophy, SVR: systematic vascular resistance, SV: stroke volume.

Figure 2

ECG of a female patient with TTS during postpartum. Widespread T-wave inversion together with ST depression in lateral precordial leads alongside marked QT prolongation.

Figure 3

CMR findings in TTS. (a) CINE 2-chamber view with typical TTS—apical ballooning; (b) T2 mapping edema accompanies TTS in acute-subacute phase (increased time in T2 mapping); (c) CMR can detect TTS complications such as LV thrombi or pericardial/pleural effusion seen in next picture; (d) LGE absence is a common finding in TTS and, if present, is commonly attributed to generalized edema, which dissolves quickly.

Figure 4

Therapeutical strategies in TTS during pregnancy or postpartum period. ACEi: angiotensin-converting enzyme inhibitors, AF: atrial fibrillation, ARNI: angiotensin receptor/neprilysin inhibitor, CS: cardiogenic shock, DM2: diabetes mellitus type 2, ECG: electrocardiogram, ECMO: extracorporeal membrane oxygenation, HF: heart failure, HTN: hypertension, IABP: intra-aortic balloon pump, LMWH: low molecular weight heparin, LVEF: left ventricular ejection fraction, LVOTO: left ventricular outflow tract obstruction, MOF: multiple organ failure, MRA: mineralocorticoid receptor antagonist, NOAC: non-vitamin K oral anticoagulants, SGLT2i: sodium-glucose cotransporter-2 inhibitor.