Case report of Tako-Tsubo cardiomyopathy associated with repetitive anaesthesia in a female patient with Tako-Tsubo cardiomyopathy

Abstract

BackgroundTako-Tsubo cardiomyopathy (TTC) is a rare disorder with high relevance for anaesthesia. It is an acute cardiac syndrome characterized by an acute onset of reversible left ventricular dysfunction associated with emotional and physical stress. This is the only case published of a patient having five severe Tako-Tsubo incidents in five consecutive general anaesthesia procedures within one year.Case presentationA 61 years old female patient (height 1.65 m; weight 70 kg) presented with a haemorrhagic pituitary adenoma with compression of the optic chiasm and was scheduled for transnasal endoscopic tumour resection. We report a case series with five consecutive anaesthesia procedures in the same patient for neurosurgery.This case series is remarkable since the severe symptoms occurred during every anaesthesia procedure. The female patient was resuscitated two times including therapeutic hypothermia, but fortunately no neurological or cognitive deficit was detectable.ConclusionsTTC may initially present in the perioperative period with pulmonary oedema, electrocardiographic (ECG) changes, elevation of cardiac enzymes, and cardiogenic shock or cardiac arrest.Since the risk of recurrence is considered to be low in TTC, this case report is of high interest. In each procedure similar clinical signs were found which resulted in severe haemodynamic derangements in every manifestation and cardiac arrest in two of the manifestations. Despite cardiopulmonary resuscitation twice, the patient survived without any neurological deficiency.

Takotsubo cardiomyopathy following resection of a fourth ventricle tumour

“…Takotsubo cardiomyopathy is a rare disorder, and although the exact prevalence is unknown, estimates suggest the frequency to be 5.2 and 0.6 per 100,000 for women and men, respectively, with 30% of these relating to an in‐hospital surgery or procedure . The major pathophysiological phenomenon is a disproportionate catecholamine discharge in response to stress, therefore exaggerated anxiety about surgery or anaesthesia , a light plane of anaesthesia, insufficient analgesia and surgical pain or stimulus have all been suggested to be inciting factors . In our case, the sympathetic surge at the point of manipulation near the brainstem was almost certainly the stimulus despite what we would consider as adequate anaesthesia and analgesia.…”

“…Takotsubo cardiomyopathy may present in the peri‐operative period in a myriad of ways including pulmonary oedema, ECG changes, elevation of cardiac enzymes, hypotension, cardiogenic shock or cardiac arrest . The two most commonly described symptoms are acute substernal chest pain and dyspnoea, both being described on emergence .…”

“…There are no controlled data to define an optimal medical regimen, but it seems reasonable to treat these patients with the standard medications that are used for left ventricular systolic dysfunction, including β‐adrenergic antagonists, angiotensin‐converting enzyme (ACE) inhibitors and diuretics. Medications such as β‐blockers are often advocated to counteract the hyper‐catecholamine state, while ACE inhibitors or angiotensin receptor blockers may improve survival at 1 year .…”

“…There are multiple criteria for the diagnosis of takotsubo cardiomyopathy, with the most widely cited being the 2008 Mayo Clinic criterion. This requires: Transient akinesia or dyskinesia of left ventricular apical and/or midventricular segments (classically apical ballooning and immobility) No angiographic evidence of coronary artery stenosis or evidence of acute plaque rupture The new ECG abnormalities (ST‐segment elevation or T‐wave inversion) Absence of intracranial bleeding, phaeochromocytoma and myocarditis . …”

“…However, it is still sufficiently rare that these are reported primarily as case reports. With respect to neurosurgery only one such report relates to an intracranial operation, an endoscopic pituitary tumour adenoma resection , with the remainder being reported in spinal surgery.…”