Effects of Transcatheter Aortic Valve Replacement on Concurrent Aortic Valve Disease With Takotsubo Cardiomyopathy

An 87-year-old woman previously diagnosed with severe combined stenosis and regurgitant aortic valve disease (ASR) was rushed to our hospital with dyspnea. Electrocardiography revealed new negative T-waves. Her cardiac troponin-I and brain natriuretic peptide (BNP) levels were 3461 pg/mL (normal <26 pg/mL) and 4678 pg/mL (normal <18 pg/mL), respectively. Echocardiography revealed severe ASR (Figure 1A, Supplemental Video 1) as well as new left ventricular dysfunction with apical hypokinesia and basal hyperkinesia (Figure 1B, Supplemental Video 2). Considering the absence of coronary stenosis, as documented by coronary computed tomography (Figure 1C), the worsening heart failure was attributed to Takotsubo cardiomyopathy. Despite initiating intensive drug therapy, the patient continued to remain in refractory heart failure. Consequently, we performed transcatheter aortic valve replacement (TAVR) on the 10th hospital day. As the patient had narrow iliac arteries, severely calcified aortic arch branches, and hemodynamic instability, a 26 mm self-expandable valve was implanted via a direct transaortic approach with extracorporeal membrane oxygenation support (Figure 1D). The TAVR procedure was uneventful with no postoperative complications, including left ventricular outflow tract obstruction. One week after TAVR, the left ventricular asynergy tended to improve, and the patient could be weaned from inotropes and diuretics after a temporary increase in BNP levels induced by tapered drug dosage (Figure 1E). Following 7 weeks of TAVR, the left ventricular wall motion was normalized (Figure 1F, Video 3) and BNP level decreased to 228 pg/mL. To our knowledge, this is the first report of TAVR in a patient with Takotsubo cardiomyopathy. High BNP level is associated with poor clinical outcome in patients with Takotsubo cardiomyopathy.1Murakami T. Yoshikawa T. Maekawa Y. et al.Characterization of predictors of in-hospital cardiac complications of Takotsubo cardiomyopathy: multi-center registry from Tokyo CCU Network.J Cardiol. 2014; 63: 269-273https://doi.org/10.1016/j.jjcc.2013.09.003Abstract Full Text Full Text PDF PubMed Scopus (69) Google Scholar Increased afterload due to left ventricular basal hyperkinesia is associated with cardiogenic shock,2Ghadri J.R. Wittstein I.S. Prasad A. et al.International expert consensus document on Takotsubo syndrome (part II): diagnostic workup, outcome, and management.Eur Heart J. 2018; 39: 2047-2062https://doi.org/10.1093/eurheartj/ehy077Crossref PubMed Scopus (475) Google Scholar and left ventricular unloading with percutaneous circulatory support devices are effective.3Medina de Chazal H. Del Buono M.G. Keyser-Marcus L. et al.Stress cardiomyopathy diagnosis and treatment: JACC state-of-the-art review.J Am Coll Cardiol. 2018; 72: 1955-1971https://doi.org/10.1016/j.jacc.2018.07.072Crossref PubMed Scopus (303) Google Scholar,4von Mackensen J.K.R. Zwaans V.I.T. El Shazly A. et al.Mechanical circulatory support strategies in Takotsubo syndrome with cardiogenic shock: a systematic review.J Clin Med. 2024; 13: 473https://doi.org/10.3390/jcm13020473Crossref Scopus (0) Google Scholar In this high-risk case, pressure and volume loads due to ASR could be the 2 major hindrances in controlling heart failure owing to Takotsubo cardiomyopathy. Considering the hypothesis, TAVR was effective in reducing the pressure and volume loads significantly and should therefore be weighed as a treatment option in such cases. None. The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.