Cardiovascular Disease: Student/Resident Case Report Poster - Cardiovascular Disease II |

Medication-Induced Complete Heart Block and Biventricular Takotsubo Cardiomyopathy in a Heart-Lung Transplant Recipient FREE TO VIEW

Thomas Robertson, MD; Eric Nolley, MD; Morris Alison, MD
Author and Funding Information

UPMC, Pittsburgh, PA

Copyright 2016, American College of Chest Physicians. All Rights Reserved.

Chest. 2016;150(4_S):102A. doi:10.1016/j.chest.2016.08.110
Text Size: A A A
Published online

SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease II

SESSION TYPE: Student/Resident Case Report Poster

PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM

INTRODUCTION: Takotsubo cardiomyopathy is a non-ischemic cardiomyopathy characterized by transient apical ballooning of the left ventricle in the absence of coronary artery disease. Rarely, Takotsubo can present with isolated right ventricular or biventricular involvement. We describe a patient who developed biventricular Takotsubo cardiomyopathy after receiving neostigmine 14 years post heart-double lung transplant.

CASE PRESENTATION: A 50 year old female patient who had undergone a heart and double lung transplant 14 years prior for primary pulmonary hypertension presented to the medical intensive care unit for hypotension and bradycardia after receiving neostigmine during an elective bronchoscopy. During the procedure, infiltration of an IV line pumping Rocuronium was noted. Neostigmine was administered for reversal of neuromuscular blockade, and was complicated by bradycardia and hypotension. A stat TTE revealed decreased ejection fraction and biventricular apical hypokinesis and ballooning with preserved function at the bases consistent with biventricular Takotsubo cardiomyopathy. The patient remained intubated and was transferred to the MICU where her rhythm progressed to complete heart block. Norepinephrine drip was started for the hypotension and a transvenous pacemaker was eventually placed with good capture. The patient’s hemodynamics stabilized. A subsequent endomyocardial biopsy did not reveal any pathological evidence of rejection. EKG revealed inferior T-wave inversions which resolved and a troponin-I peak of 1.91. Left heart catheterization was not pursued. The patient subsequently made a full recovery and did not require further electrical or mechanical cardiac support.

DISCUSSION: Takotsubo cardiomyopathy is an important and prevalent cause of acute, reversible non-ischemic cardiomyopathy. While primarily involving the isolated left ventricle, biventricular involvement is rare and reported only once prior in a heart transplant recipient 1. A novel aspect of this case is the association of Takotsubo with neostigmine administration, which to our knowledge has never been reported. Data show that recipients greater than six months from their heart transplant are particularly sensitive to the effects of neostigmine on heart rhythm 2, and as we saw here, the potential for more serious side effects.

CONCLUSIONS: Biventricular Takotsubo cardiomyopathy is a rare variant of the more common transient LV apical ballooning syndrome. Neostigmine induced biventricular involvement is a novel case presentation and the dose-dependent effects of neostigmine should be considered prior to administration in heart transplant recipients.

Reference #1: Behnes, et al. Biventricular Takutsubo Cariomyopathy in a Heart Transplant Recipient. Circulation. 2013; 128: e62-e63

Reference #2: Backman, et al. Neostigmine reduces heart rate in heart transplant patients. Can J Anaesth. 1996 Apr;43(4):373-8

DISCLOSURE: The following authors have nothing to disclose: Thomas Robertson, Eric Nolley, Morris Alison

No Product/Research Disclosure Information




Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Find Similar Articles
CHEST Journal Articles
  • CHEST Journal
    Print ISSN: 0012-3692
    Online ISSN: 1931-3543