Reverse Takotsubo Cardiomyopathy After an Adverse Reaction to Alteplase Treated with Intravenous Epinephrine

Abstract

Takotsubo (stress) cardiomyopathy (TTC) is an uncommon acute heart failure syndrome characterized by transient hypocontractility that usually affects a circumferential segment of the myocardium along the heart's apicobasal axis and spans multiple coronary artery territories. Classically, TTC occurs after an intense physical or emotional insult and is thought to be caused by catecholamine toxicity. The most frequent anatomic variant presents with apical hypokinesis and basal hyperkinesis, but the hypocontractility may also localize to the mid-ventricle or base, also known as "reverse TTC." Here, we describe a middle-aged woman who developed profound acute hypoxemic respiratory failure and mixed cardiogenic-distributive shock after an adverse reaction to alteplase treated with high-dose epinephrine. The patient was found to have a severely depressed left ventricular ejection fraction (10-15%) with apex-sparing hypokinesis and no evidence of obstructive coronary artery disease, consistent with reverse TTC. The patient's ejection fraction recovered to the normal range within days with supportive measures. This case highlights the distinctive echocardiographic features of this rare, potentially life-threatening form of TTC.Videos are available for this article.

Keywords: Alteplase; Echocardiography; Epinephrine; Reverse takotsubo cardiomyopathy; Stress cardiomyopathy.

Fig. 1

12-lead electrocardiogram obtained 35 min after the initial epinephrine bolus. The electrocardiogram shows normal sinus rhythm at 75 beats per minute with a normal axis and normal intervals. Diffuse T-wave inversions and flattening are observed. Significant down-sloping ST-segment depressions (≥ 0.5 mm) are present diffusely but are most pronounced (≥ 1 mm) in leads V₁–V₅

Fig. 2

Transesophageal echocardiogram obtained 25 min after the initial epinephrine bolus. Representative images from the mid-esophageal four-chamber view (transducer angle 0°) are shown at A end-diastole and B end-systole. Representative images from the mid-esophageal long-axis view (transducer angle 116°) are shown at C end-diastole and D end-systole. Significant contractility is observed only in the apical third of the left ventricle. The basal and mid-segments of the left ventricle appear nearly akinetic. The mid- and basal segments of the interventricular septum bow into the right ventricle. E Doppler imaging of the mitral valve showing a small, central regurgitant jet

Fig. 3

Transthoracic echocardiogram obtained 4.5 h after the initial epinephrine bolus. Representative images from the apical four-chamber view are shown at A end-diastole and B end-systole. Representative images from the apical two-chamber view are shown at C end-diastole and D end-systole. Relative to Fig. 2, increased contractility is visualized in the mid- and basal segments of the left ventricle. E Polar plot of the longitudinal strain mapping derived from this echocardiogram, illustrating basal-predominant hypokinesis with relative apical sparing

Fig. 4

Transthoracic echocardiogram obtained 5 days after the aborted procedure. Representative images from the apical four-chamber view are shown at A end-diastole and B end-systole. Representative images from the apical two-chamber view are shown at C end-diastole and D end-systole. The contractile function of the basal two-thirds of the left ventricle appears grossly recovered. The septal bowing observed in Figs. 2 and 3 is no longer evident