Case Presentation: The patient is a 58-year-old hispanic man with a past medical history of decompensated hepatitis C virus, alcoholic cirrhosis, hepatocellular carcinoma (HCC), and asthma who presented for definitive management of his known hepatic mass. Based on prior work up and imaging, this mass was presumed to be HCC. He presented to the hospital for elective outpatient ethiodol embolization and microwave ablation of his right hepatic lesion. Following his procedure, he experienced severe shortness of breath with desaturation to the low 80s on room air, and required BiPAP. He was found to have an elevated lactate of 4.60 and was provided intravenous fluid boluses and started on maintenance fluids overnight. The following morning, his lactate had worsened to 9.70 despite fluid resuscitation, and he was noted to have jugular venous distention. An echocardiogram was completed and demonstrated diffuse apical hypokinesis concerning for Takotsubo cardiomyopathy. This was further supported due to the patient having had an echocardiogram done two months prior with normal left ventricular function. He was provided intravenous diuretics and responded well with clinical improvement. He eventually transitioned to oral diuretics, and was started on carvedilol and lisinopril. He was discharged with close follow up with cardiology. He underwent repeat echocardiography five months after discharge which demonstrated recovery of apical wall function.
Discussion: Takotsubo cardiomyopathy (TC) is a rare phenomenon, and as such, prevalence is based on patients presenting with acute coronary syndrome (ACS) or troponin elevation. In these patients, 1.2-2.2% are found to have TC, rather than true ACS or myocardial ischemia/infarction (1,2). The clinical manifestations of TC are often identical to those of acute decompensated heart failure including dyspnea, hypoxia, jugular venous distention, and lower extremity edema. It is known as “broken heart syndrome” as it occurs primarily in patients who have recently undergone periods of substantial emotional stress. However, the pathophysiology of Takotsubo is not well-elucidated. The most widely-accepted theory is that of elevated levels of circulating catecholamines and their metabolites due to underlying stress. As such, it can also manifest in patients who have experienced physical stressors, such as surgical procedures.
Conclusions: Takotsubo cardiomyopathy occurs primarily in patients with substantial amounts of physical or emotional stressors. For this reason, it should be considered within a list of differentials for patients in the post-operative state with acute symptoms of heart or respiratory failure.