Aborted Sudden Cardiac Death in a Female Patient Presenting with Takotsubo-Like Cardiomyopathy due to Epicardial Coronary Vasospasm

Abstract

Takotsubo cardiomyopathy is characterized by apical ballooning of the left ventricle (LV) in the absence of relevant coronary artery stenosis, which typically occurs in elderly women after emotional stress. Catecholamine cardiotoxicity, metabolic disturbance, and coronary microvascular impairment have previously been proposed as underlying pathophysiologic mechanisms of takotsubo cardiomyopathy, whereas myocardial stunning resulting from epicardial coronary artery vasospasm is not generally accepted as a cause of takotsubo cardiomyopathy. The prognosis of takotsubo cardiomyopathy is generally more favourable compared to myocardial infarction; however, severe complications such as rupture of the LV and life-threatening arrhythmias may occur. Herein, we describe a case of an 84-year-old female, who presented with aborted sudden cardiac death due to ventricular fibrillation. Echocardiography suggested LV apical ballooning with severely impaired LV-function, so that takotsubo cardiomyopathy was suspected. However, coronary angiography revealed epicardial spasm of the left anterior ascending, which resolved after intracoronary injection of 0.2 mg nitroglycerine. Cardiac magnetic resonance exhibited subendocardial late enhancement and echocardiography showed normalization of LV dysfunction during follow-up. The patient was put on conservative treatment with nitrates and calcium inhibitors and ICD implantation were deferred.

A valuable cardiac magnetic resonance investigation after MINOCA/takotsubo Syndrome: a case report

“…Another possible variant of this scenario is that our patient had prolonged coronary vasospasm of a major coronary artery during the acute phase (which might have contributed to CMR oedema), with or without superimposed TTS, that subsequently developed into a subendocardial infarct after discharge. Indeed, there have been isolated reports of concurrent coronary vasospasm and TTS 15,16 . Given that the patient's EF returned to normal, it is perhaps more likely that the concurrent or subsequent ischaemic event had a transient aetiology rather than representing a “typical” occlusive MI.…”

“…Indeed, there have been isolated reports of concurrent coronary vasospasm and TTS. 15,16 Given that the patient's EF returned to normal, it is perhaps more likely that the concurrent or subsequent ischaemic event had a transient aetiology rather than representing a "typical" occlusive MI.…”

Pathogenesis of Ventricular Arrhythmias and Its Effect on Long-Term Prognosis in Patients With Takotsubo Cardiomyopathy

“…The first one depicted a 51-year-old female with syncope, recurrent shortness of breath and palpitations, with polymorphic VT one year after the initial presentation [ 22 ]. The second one is of an 84-year-old woman who presented with SCD secondary to VF [ 23 ]. There was no emotional or physical stress on either one of the patients, but one had a personal history of tobacco use.…”

Another typical ST-segment elevation myocardial infarction in the elderly?

“…LAD IVUS would have delayed the proper diagnosis in the context of a supposed exclusive LAD spasm. Although coronary spasm and takotsubo cardiomyopathy were once considered separate entities, there is convincing evidence of a common pathophysiology5 6 and there are case reports with this provoked6 and spontaneous7 association. LAD primary angioplasty was not indicated because there was no evidence of acute coronary thrombosis.…”