Percutaneous mechanical hemodynamic support as a bridge to recovery in severe takotsubo cardiomyopathy with profound left ventricular outflow tract obstruction and cardiogenic shock
Mawri S, Fuller B, Koenig G, Parikh S, Zaidan M. Percutaneous mechanical hemodynamic support as a bridge to recovery in severe takotsubo cardiomyopathy with profound left ventricular outflow tract obstruction and cardiogenic shock. J Am Coll Cardiol. 2018;71(11)
J Am Coll Cardiol
Background: Takotsubo Cardiomyopathy (TC) in severecases may present with profound LV outfow tract (LVOT) obstruction and cardiogenic shock, posing management challenges for clinicians, since inotropes and vasopressor use can exacerbate LVOT obstruction, potentially yielding catastrophic consequences. Case: A 55-year-old man presented with typical chest pain, hypotension (BP 87/64 MMHG) and hypoxic respiratory distress requiring urgent intubation. ECG showed precordial St elevations and cardiac biomarkers were elevated. ACS therapy and IV fuids were given, and dobutamine and levophed infusions were initiated for presumed anterior STEMI with cardiogenicshock. Urgent LHC revealed LVEDP of 40 MMHG. An LV Impella 3.5L was placed for hemodynamic support. Coronary angiogram revealed normal coronaries. TTE showed EF of 35% with basal hyperkinesis and severehypokinesis of mid to distal anterior, inferior, and apical walls consistent with TC, and SAM resulting in signifcant LVOT obstruction (peak gradient 71 MMHG). After 2 days with Impella support and titration off pressors, he recovered and was weaned off mechanical support. Repeat TTE on day 4 was completely normal. Decision-making: TC causes transient LV dysfunction and regional wall motion abnormalities that mimic ACS. It's usually preceded by emotional or physical stress and typically only requires supportive care, with associated low in-hospital mortality risk. However, in rare circumstances, TC may cause marked dynamic LVOT obstruction and cardiogenic shock (CS), mimicking acute MI with CS. It is important to differentiate between the two, since immediate management strategy vastly differs. While positive inotropic support and IABP may improve hemodynamics in AMI CS, these worsen dynamic LVOT gradients in TC and may be catastrophic. Rather, IV fuids and beta blockers (BB) are given to reduce LVOT obstruction. When these are insuffcient, active LV unloading with mechanical support devices may serve as abridge to recovery. Conclusion: Temporary mechanicalsupport may provide rapid hemodynamic stabilization incases of severe TC with signifcant LVOT obstruction and shock, where medical therapy is inadequate.