Differential Diagnosis of Transient Left Ventricular Dysfunction in a Critically Ill Patient

Abstract

There is evidence illustrating that the etiologies of non-ischemic LV (left ventricular) dysfunction such as Takotsubo cardiomyopathy, neurogenic stunning myocardium and post resuscitation stunning myocardium have a favorable clinical outcome. Good prognosis in non-ischemic LV dysfunction provides us courage to treat the condition expecting good. We describe herein the unique case of a 33-year-old woman who was started on combination chemotherapy of oxaliplatin and 5-flurouracil for colon adenocarcinoma. The patient's baseline QTc was 460 ms. Twenty-four hours following initiation of chemotherapy, the patient developed 3 discrete episodes of tonicclonic seizures. Electrocardiogram assessment demonstrated a prolonged QTc interval (623 ms) with several episodes of TdP. Two episodes required defibrillation to revert to sinus rhythm. Post resuscitation echocardiogram showed severe global LV dysfunction with ejection fraction of 33%. The patient subsequently required mechanical ventilation due to severe LV dysfunction with pulmonary edema. Possible etiologies for LV dysfunction in the present case include global Takotsubo cardiomyopathy, neurogenic stunning myocardium or post resuscitation stunning myocardium. Repeat echocardiogram 48 h later showed the ejection fraction of 60%. Although myocardial dysfunction associated with Takotsubo cardiomyopathy, neurogenic stunning myocardium and post resuscitation stunning myocardium have been previously described independently, the present case is unique in that, to our knowledge, torsade de pointes presented with transient left ventricular dysfunction following several episodes of seizures and post resuscitation stunning myocardium that were stabilized in one patient following oxaliplatin and 5-fluorouracil infusion has not been reported. Case ReportA 33-year-old female patient who underwent hemicolectomy for colon adenocarcinoma was admitted for chemotherapy. Her past medical history was unremarkable and notably, not significant for cardiovascular, respiratory or neurological disorders. She did not have intracranial metastasis. The patient was not on any medications that could affect the QT interval. Baseline blood investigations including electrolytes and renal parameters were within normal limits. The physical examination was unremarkable. Baseline electrocardiogram demonstrated normal sinus rhythm, normal PR interval and the Bazett-corrected QT interval was 460 ms. Echocardiogram showed normal size cardiac chambers, no regional wall motion abnormality and good LV systolic function, with ejection fraction of 67%.Chemotherapy regimen was modified Folfox consisting of oxaliplatin 85 mg/m 2 intravenous on Day 1, 5-FU 400 mg/m 2 intravenous bolus on Day 1, followed by continuous infusion 1500 mg/m 2 for 22 h on Day 1 and 2. Leucovorin (folinic acid) 75 mg/m 2 was given as continuous infusion on Day 1 and 2.Twenty-four hours after initiation of chemotherapy, the patient developed a seizure that was initially treated with intravenous diphenylhydantoin in the ward. Withi...