Reverse Takotsubo Cardiomyopathy After an Adverse Reaction to Alteplase Treated with Intravenous Epinephrine

Figures

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  Fig. 1. 12-lead electrocardiogram obtained 35 min after the initial epinephrine bolus. The electrocardiogram shows normal sinus rhythm at 75 beats per minute with a normal axis and normal intervals. Diffuse T-wave inversions and flattening are observed. Significant down-sloping ST-segment depressions (≥ 0.5 mm) are present diffusely but are most pronounced (≥ 1 mm) in leads V1–V5

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  Fig. 2. Transesophageal echocardiogram obtained 25 min after the initial epinephrine bolus. Representative images from the mid-esophageal four-chamber view (transducer angle 0°) are shown at A end-diastole and B end-systole. Representative images from the mid-esophageal long-axis view (transducer angle 116°) are shown at C end-diastole and D end-systole. Significant contractility is observed only in the apical third of the left ventricle. The basal and mid-segments of the left ventricle appear nearly akinetic. The mid- and basal segments of the interventricular septum bow into the right ventricle. E Doppler imaging of the mitral valve showing a small, central regurgitant jet

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  Fig. 3. Transthoracic echocardiogram obtained 4.5 h after the initial epinephrine bolus. Representative images from the apical four-chamber view are shown at A end-diastole and B end-systole. Representative images from the apical two-chamber view are shown at C end-diastole and D end-systole. Relative to Fig. 2, increased contractility is visualized in the mid- and basal segments of the left ventricle. E Polar plot of the longitudinal strain mapping derived from this echocardiogram, illustrating basal-predominant hypokinesis with relative apical sparing

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  Fig. 4. Transthoracic echocardiogram obtained 5 days after the aborted procedure. Representative images from the apical four-chamber view are shown at A end-diastole and B end-systole. Representative images from the apical two-chamber view are shown at C end-diastole and D end-systole. The contractile function of the basal two-thirds of the left ventricle appears grossly recovered. The septal bowing observed in Figs. 2 and 3 is no longer evident