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Takotsubo cardiomyopathy

BMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1272 (Published 26 March 2010) Cite this as: BMJ 2010;340:c1272

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Takotsubo Cardiomyopathy - an underdiagnosed complication of anaesthesia?

Dear Sir

We read with interest the recent editorial on Takotsubo
Cardiomyopathy (TC) by Cuculi et al 1. In association with general
anaesthesia, we would like to further emphasise the importance of
recognising this serious but reversible cause of acute myocardial
dysfunction. We recently admitted a 43 year old gentleman to our remote
ambulatory day case unit for an elective laparoscopic cholecystectomy. He
was systemically well with no significant co-morbidities at the
preoperative assessment. However, he reported extreme anxiety about the
procedure as he had never been in hospital before. He arrived on the
morning of his procedure, was consented and taken for his operation.

Anaesthetic induction and the operative procedure went uneventfully but
shortly after emergence and extubation he developed acute respiratory
failure necessitating reintubation and transfer to our intensive care
unit, a 20 mile transfer. Clinical and radiological findings confirmed
acute pulmonary oedema and an initial ECG revealed a sinus tachycardia.

Echocardiography revealed dyskinesis of apical and mid ventricular
segments with normokinesis of basal segments and a reduced ejection
fraction. This 'apical ballooning' of the left ventricle (LV) raised the
suspicion of TC. Within 12 hours deep T wave inversion developed on all
chest leads on ECG and Troponin T was mildy elevated at 0.52 µg/L (normal
range Coronary angiography performed the following morning confirmed non-
obstructive coronary arteries and a left ventriculogram confirmed the
echocardiographic findings with LV apical ballooning and an ejection
fraction of 36%. He was successfully weaned from mechanical ventilation
and extubated following angiography. He was subsequently started on beta
blockers by the cardiologists and discharged from hospital with outpatient
follow up a few days later. His LV function was normal on echocardiography
2 months later.

TC has been reported in the literature before in assocation with
general anaesthesia but we would like to raise a few concerns 2. With the
increased drive in more day case procedures will we see this phenomenon
more often? Patients turn up on the morning of surgery, anxious. No
premedication is possible due to consenting issues and obviously the
patient needs to be discharged later that day. This sounds like a recipe
for Takotsubo cardiomyopathy!

Additionally, as anaesthetists we are all aware of the cases of
'negative pressure pulmonary oedema' on emergence from general
anaesthesia. This has been attributed to intrapulmonary negative pressure
created by the patient spontaneously breathing on the endotracheal tube or
laryngeal mask whilst emerging from anaesthesia. We propose that this
indeed may be accounted for by takotsubo cardiomyopathy. Emergence is a
stressful time for the patient, they may be in pain and the pulmonary
oedema that ensues is generally reversible over the next few hours with a
bit of patience. This again sounds like a recipe for Takotsubo
cardiomyopathy.

The incidence of TC in the perioperative period is unknown and we
would paraphrase Cuculi et al's title of their editoral 'An important
differential diagnosis in patients with acute myocardial dysfunction in
the perioperative period'. Although reversible, this condition does have a
mortality hence why it was coined 'broken heart syndrome'.

References

1. A P Banning, F Cuculi, and C C S Lim
Takotsubo cardiomyopathy BMJ 2010; 340: c1272

1. Gavish D, Rozenman Y, Hafner R, Bartov E, Ezri T. Takotsubo
cardiomyopathy after general anesthesia for eye surgery. Anesthesiology
2006; 105: 621-3.

Competing interests:
None declared

Patient consent obtained.

Fig. Coronary angiography and LV ventriculography revealing non-obstructive coronary arteries and apical ballooning.

Competing interests: No competing interests

04 June 2010
Peter J O'Brien
Specialist Registrar ICM
Adnan Nadir, Stephan Koch, Stephen J Cole, and Neil MacKenzie
Ninewells Hospital, Dundee, DD5 3GG