Alicia M Kowalski

The University of Texas MD Anderson Cancer Center

Abstract Title: Peri-Operative Takotsubo Cardiomyopathy: A Case Series

Biography:

Research Interest: Takotsubo Cardiomyopathy (TC) is a reversible, stress-induced, non-ischemic cardiomyopathy with temporary weakness of the myocardium and midventricular or apical ballooning.1 Angina, ST abnormalities, elevated troponins, ventricular asynergy, congestive heart failure (CHF), and decreased ejection fraction (EF) are all components. The unique finding is the absence of coronary artery disease (CAD).2 Patients with a history of TC are likely to recur in up to 10%.3 With proper interventions, TC has a favorable prognosis with cardiac function returning to normal. In this case series with institutional review board (IRB) approval we report four cases of post-operative cardiac symptoms resulting in a diagnosis of TC. DISCUSSION Acute MI and TC are indistinguishable. Catheterization is required to rule out occlusive CAD. The trigger is a stressful or emotional event in ~90% of patients.1 Pathognomonic is LV apical wall ballooning (not corresponding to any specific coronary artery territory2) in the presence of normal coronary arteries. Etiology points to activation of the sympathetic nervous system: patients are found to have high levels of circulating catecholamines, up to 7-34 times normal, compared to 2-3 times normal for patients experiencing acute MI1, 3 Patients with hyperlipidemia, hypertension, smoking, alcohol abuse, anxiety state, depression, and stress had higher odds of developing TC.4 Curiously, women have higher odds (ratio to men of >6:1)5, and women > 55yo 4.8 times higher.4 Asian and Caucasian women have higher incidence.3 Contributing factors are likely smaller left ventricle, hormonal disturbances, and decreasing vagal tone and baroreflex sensitivity in postmenopausal women.5 Treatment is goal-directed: reduce myocardial workload and offload SVR. Interventions vary from medication management to intra-aortic balloon pump in acute LV failure.3 Typically, LV function is restored within days to weeks. 33% of patients have spontaneous recovery of LV function by discharge.3 95% of patients experience a full recovery within 4–8 weeks. Mortality <2%6 CONCLUSION In the perioperative setting, signs and symptoms that suggest a myocardial infarction can be due to TC. References: 1. The American Journal of Cardiology, Volume 112, Issue 1, 1 July 2013, Pages 137–138. 2. International Journal of Cardiology, Volume 142, Issue 2, 9 July 2010, Pages 120–125. 3. Nurse Pract. 2012 Oct 10;37(10):48-52. 4. Am Heart J. 2012 Jul;164(1):66-71.e1. di: 10.1016/j.ahj.2012.03.020. Epub 2012 Jun 13. 5. Am J Cardiol. 2013 Mar 1;111(5):778. doi: 10.1016/j.amjcard.2012.10.023 6. Br J Anaesth. 2013 Mar;110(3):487-8. doi: 10.1093/bja/aes586