Perioperative Management of Cancer Patients With Chemotherapy-Associated Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a stress-induced cardiomyopathy characterized by transient left ventricular systolic dysfunction in the absence of obstructive coronary artery disease. Although recovery of left ventricular ejection fraction is common, TTC is associated with measurable morbidity and mortality. The condition accounts for approximately 1% to 2% of suspected acute coronary syndrome presentations and is increasingly recognized in oncology patients receiving systemic therapy. Chemotherapy-associated TTC has been reported with fluoropyrimidines, antivascular endothelial growth factor agents, platinum-based regimens, and immune checkpoint inhibitors. Proposed mechanisms include endothelial dysfunction, coronary vasospasm, inflammation, oxidative stress, and autonomic dysregulation. The perioperative environment may reproduce these triggers through sympathetic activation and hemodynamic instability, thereby increasing the risk of recurrence. Perioperative management should be guided by the timing and severity of TTC (active, recent, or remote). It should include structured preoperative assessment, individualized anesthetic planning, cautious selection of vasoactive agents, and vigilant postoperative monitoring. This review synthesizes current evidence and provides practical guidance for anesthesiologists managing patients with chemotherapy-associated TTC undergoing noncardiac surgery.