Takotsubo cardiomyopathy in a patient with esophageal cancer: a case report

Login or register to view PDF.
Abstract

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, has increasingly been reported in the medical literature in recent years. While case series outlining the clinical features of the disease have now been published, much is still unknown regarding risk factors and clinical relationships. We contribute this case report to the growing set of literature on the topic.

Case presentation
A 64-year-old woman with unresectable squamous cell carcinoma of the mid esophagus was treated with definitive chemoradiotherapy, including 4500 cGy of external beam radiotherapy and two cycles of cisplatin and a continuous venous infusion of 5-fluorouracil. Three months later, she was admitted to the hospital with new onset of choking with both solid and liquid foods. Her past medical history included generalized anxiety disorder and hypercholesterolemia. She had an extensive smoking history, but no known history of cardiac disease. A barium esophagram on admission revealed a tracheo-esophageal fistula for which she underwent a successful endoscopic stent placement with a self-expanding metallic stent.

Pages

One day after the procedure, the patient developed substernal chest pain. Serial electrocardiograms revealed ST elevation in the anterior and lateral leads. Troponin measurements rose to 12.3 ng/ml; serum creatine kinase MB peaked at 10.6 ng/ml. Echocardiography revealed severely reduced global left ventricular systolic function and normal basal systolic function. Regional wall motion abnormalities were noted in the left anterior descending, left circumflex and right coronary artery distributions. The patient developed clinical signs of left-sided heart failure, including acute hypoxemic respiratory failure, and required intubation and mechanical ventilation. An emergency cardiac catheterization revealed normal, patent coronary arteries. A left ventriculogram revealed apical dilation of the left ventricle with akinesis of the whole ventricle except for the anterior and posterior base (Figure 1). Cardiology consultants felt that the patient's clinical and echocardiographic features met the diagnostic criteria for takotsubo cardiomyopathy [1]. The patient was managed conservatively with diuresis and had a rapid clinical improvement; she was extubated after 2 days. She was found to have marked improvement in regional wall motion and left ventricular systolic function on a repeat echocardiogram 6 days later (Figures 2 and 3). She had no clinical signs of congestive heart failure during follow-up 2.5 weeks later, making an ischemic or radiation induced irreversible cardiomyopathy unlikely.

 

 

 

Published online 2008 December 8. doi: 10.1186/1752-1947-2-379.
Copyright ├é┬® 2008 Gangadhar et al; licensee BioMed Central Ltd.]\">
  Figure 1
Left ventriculography during systole showing apical ballooning akinesis with basal hyperkinesis in a characteristic takotsubo ventricle.

 

 

 

Published online 2008 December 8. doi: 10.1186/1752-1947-2-379.
Copyright ├é┬® 2008 Gangadhar et al; licensee BioMed Central Ltd.]\">
  Figure 2
Echocardiograph showing dilatation of the left ventricle in the acute phase.
Published online 2008 December 8. doi: 10.1186/1752-1947-2-379.
Copyright ├é┬® 2008 Gangadhar et al; licensee BioMed Central Ltd.]\">
  Figure 3
Resolution of left ventricular function on repeat echocardiograph 6 days later.

Pages

References
  1. Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, Rihal CS. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141:858├óÔé¼ÔÇ£865.
  2. Abe Y, Kondo M, Matsuoka R, Araki M, Dohyama K, Tanio H. Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol. 2003;41:737├óÔé¼ÔÇ£742. doi: 10.1016/S0735-1097(02)02925-X.
  3. Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Koike H, Sasaka K. The clinical features of takotsubo cardiomyopathy. QJM. 2003;96:563├óÔé¼ÔÇ£573. doi: 10.1093/qjmed/hcg096.
  4. Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, Yoshiyama M, Miyazaki S, Haze K, Ogawa H. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina pectoris-myocardial infarction investigations in Japan. J Am Coll Cardiol. 2001;38:11├óÔé¼ÔÇ£18. doi: 10.1016/S0735-1097(01)01316-X.
  5. Seth PS, Aurigemma GP, Krasnow JM, Tighe DA, Untereker WJ, Meyer TE. A syndrome of transient left ventricular apical wall motion abnormality in the absence of coronary disease: a perspective from the United States. Cardiology. 2003;100:61├óÔé¼ÔÇ£66. doi: 10.1159/000073040.
  6. Desmet WJ, Adriaenssens BF, Dens JA. Apical ballooning of the left ventricle: first series in white patients. Heart. 2003;89:1027├óÔé¼ÔÇ£1031. doi: 10.1136/heart.89.9.1027.
  7. Ueyama T, Kasamatsu K, Hano T, Yamamoto K, Tsuruo Y, Nishio I. Emotional stress induces transient left ventricular hypocontraction in the rat via activation of cardiac adrenoceptors: a possible animal model of 'tako-tsubo' cardiomyopathy. Circ J. 2002;66:712├óÔé¼ÔÇ£713. doi: 10.1253/circj.66.712.
  8. Ueyama T, Senba E, Kasamatsu K, Hano T, Yamamoto K, Nishio I, Tsuruo Y, Yoshida K. Molecular mechanism of emotional stress-induced and catecholamine-induced heart attack. J Cardiovasc Pharmacol. 2003;41:S115├óÔé¼ÔÇ£118.
  9. Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J. 2006;27:1523├óÔé¼ÔÇ£1529. doi: 10.1093/eurheartj/ehl032.
  10. Bybee KA, Prasad A, Barsness GW, Lerman A, Jaffe AS, Murphy JG, Wright RS, Rihal CS. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol. 2004;94:343├óÔé¼ÔÇ£346. doi: 10.1016/j.amjcard.2004.04.030.