Echocardiographic Findings of Stress Cardiomyopathy in a Young Parturient with Acute Abdomen

To the Editor, We present a case of a young healthy parturient who was admitted to our hospital for scheduled caesarian delivery. The procedure was uneventful. A week later, the patient was transferred to the operating theater due to bowel perforation. During surgery, she became hemodynamically unstable (blood pressure: 70/40 mmHg, heart rate: 95 pulse/min) requiring treatment with vasopressors and fluids. Postoperatively, the patient was transferred to the intensive care unit (ICU). The electrocardiogram revealed ST segment in V2-V6 leads. Troponin and pro-brain natriuretic peptide levels were moderately elevated. A transthoracic echocardiography (TTE) examination was performed by an anesthetist who was competent at TTE (certified by the European Association of Cardiovascular Imaging). The two-dimensional (2D) imaging revealed reduced left ventricular (LV) function with ejection fraction (EF) of 40%. Akinesia of the apex (mainly at the apical interventricular septum) and hypercontractile basal myocardial segments were visualized [https://links.lww.com/AOCA/A407]. Speckle-tracking echocardiography revealed reduced global longitudinal peak systolic strain (GLPSS):15.9%, [Figure 1]. Strain values were low in the LV apex and in all the basal hyperkinetic segments (apart from the inferior wall). The coronary angiogram was negative for coronary disease. The diagnosis of stress cardiomyopathy (SC) was established.[1234] The patient was weaned off of vasopressors and discharged from the ICU 4 days later. She was referred to the cardiology department since her cardiac function had not completely recovered.Figure 1: Speckle-tracking echocardiography with reduced global longitudinal peak systolic strain. Strain values are low in the apex of the left ventricle and in all the basal hyperkinetic segments except for the inferior myocardial wallIn SC, the most characteristic TTE findings are apical ballooning and LV regional wall motion abnormalities in an area extending beyond the territory of one single coronary artery that is counteracted by normal or even hyperkinetic basal contractility.[12] Electrocardiographic changes are frequently reported, and cardiac troponin is typically elevated.[12] The GLPSS can also be employed to evaluate regional myocardial function.[3] Of note, in the acute phase of SC, the longitudinal peak systolic strain changes in apical and basal segments. There is a decrease in the longitudinal peak systolic strain values from the base to the apex of the heart, with the distribution across myocardial segments taking the image of the “evil eye.”[4] Although in normal individuals, systolic longitudinal strain exhibits a small base-to-apex gradient, such that successive shortening strains are higher at the apical and mid-segments with respect to the LV base,[5] in patients with SC, significant base-to-apex gradient indicates a more severe involvement of the cardiac apex.[34] In our case, at the apex, the segmental peak longitudinal strain values were partially reduced (apical anterior and apical inferior segments: −22 and − 23, apical cap: −17, apical antero-septum: −12 and apical anterior segment: −12). However, lower strain values with more uniform distribution than the apex were found in the basal hyperkinetic segments (except for the inferior myocardial wall). A base-to apex gradient also developed which was completely opposite to that presented frequently in patients with SC.[345] It was very likely that the increased circumferential/radial function of the basal LV segments (2D imaging) compensated for the reduced longitudinal myocardial function (2D strain). In conclusion, the perioperative use of TTE by properly trained anesthetists can contribute to the diagnosis of SC. Nevertheless, it should be kept in mind that echocardiographic findings can vary and may be misleading at times. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.