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Cardiovascular Disease |

Takotsubo Cardiomyopathy in a Heart Transplant Recipient

Vincent Cunanan, MD; Sivagini Ganesh, MD; Thomas Kleisli, MD; Mark Barr, MD
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University of Southern California, Division of Pulmonary, Critical Care, and Sleep Medicine, Los Angeles, CA


Chest. 2013;144(4_MeetingAbstracts):124A. doi:10.1378/chest.1701735
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Abstract

SESSION TITLE: Cardiovascular Case Report Posters II

SESSION TYPE: Affiliate Case Report Poster

PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM

INTRODUCTION: Takotsubo cardiomyopathy is a non-ischemic cardiomyopathy characterized by apical ballooning of the left ventricle. This has been described in the cardiac literature, however, there is a paucity of information related to the incidence of this syndrome following heart transplantation. We describe a patient who developed Takotsubo cardiomyopathy 6 years after an orthotopic heart transplant.

CASE PRESENTATION: A 69 year old male who had undergone an orthotopic heart transplant 6 years prior presented with sudden respiratory distress and hypotension 30 minutes after a total shoulder arthroplasty. The patient was intubated and chest imaging was consistent with pulmonary edema and lower lobe consolidation. The patient was started on antibiotics given the possibility of sepsis in the setting of aspiration pneumonia. Intravenous methylprednisolone was started and Tacrolimus levels were maintained within a therapeutic range. Hemodynamic monitoring demonstrated a cardiac index of 1.77 L/min/m2. Transthoracic echocardiography showed moderate global hypokinesis most pronounced from the mid to distal left ventricle suggestive of an apical ballooning syndrome and an ejection fraction (EF) of 25%. Endomyocardial biopsy did not show acute cellular rejection and a coronary angiogram revealed non-obstructive coronary artery disease. At this point, a diagnosis of Takotsubo cardiomyopathy was made and inotropic support with milrinone was started. The patient subsequently improved and follow up echocardiogram 10 days after showed an improved EF of 65%. The patient recuperated without further incident.

DISCUSSION: Takotsubo cardiomyopathy typically occurs in the setting of severe emotional or physical stressors and is common among postmenopausal women. The pathophysiology centers around excessive sympathetic nervous system activation resulting in high circulating catecholamine levels in turn causing myocardial stunning. In heart transplant patients, parasympathetic denervation theoretically leads to an exaggerated response to catecholamines and may increase susceptibility to stress induced cardiomyopathy. Given the rarity of this condition, other more common differential diagnoses should also be considered such as transplant rejection and coronary ischemia. The subsequent improvement of the patient's cardiac function attests to the reversible nature of this condition.

CONCLUSIONS: Takotsubo cardiomyopathy may occur in heart transplant recipients but is a rarely reported entity. This condition should be considered in the event of an unexplained sudden decline in cardiac function in this population.

Reference #1: Pilgrim et al. Takotsubo cardiomyopathy or transient left apical ballooning syndrome: A systematic review. International Journal of Cardiology. 124. 2008. 283-292.

Reference #2: Gastwirth et al. Dobutamine stress-induced cardiomyopathy in an orthotopic heart transplant patient. The Journal of Heart and Lung Transplantation. 28 (9). 2009; 968-970.

DISCLOSURE: The following authors have nothing to disclose: Vincent Cunanan, Sivagini Ganesh, Thomas Kleisli, Mark Barr

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