Management of Takotsubo Cardiomyopathy in a Lung Transplant Recipient

Takotsubo cardiomyopathy (TTC) is characterized by transient wall motion abnormalities involving the left ventricular apex and midventricle in the absence of obstructive epicardial coronary disease (1). Such a case occurring in a lung transplantation candidate patient complicates management and can lead to a change in the planned strategy. We report the first case of TTC in this condition. Case Description A 55-year-old woman presenting with end-stage lung fibrosis was referred to our center for lung transplantation. She had been diagnosed with interstitial lung disease 3 years earlier, and over 1 month, she had developed rapidly progressive respiratory failure. Her condition had worsened 1 month before despite steroid therapy combined with cyclophosphamide. Echocardiographic evaluation had revealed normal left ventricular function and pulmonary hypertension with an estimated systolic artery pressure of 60 mm Hg. Despite optimal medical care, her respiratory condition worsened, and she eventually required artificial ventilation. She was transferred to our center under catecholamine support (0.7 mg/hr norepinephrine). Blood gas analysis showed severe hypoxia and hypercapnia (PaO2/FiO2: 82, PaCO2: 107.0 mm Hg, pH 7.25, lactate: 2.3 mmol/L). Echocardiographic evaluation revealed an akinesia of the apical and midventricular segments of the left ventricle and normal contraction of the basal segments of the left ventricle, showing a typical aspect of end-systolic left ventricular apical ballooning. Estimated left ejection fraction was approximately 30% (Fig. 1). No outflow tract obstruction was visible at this time. The right ventricle was moderately enlarged with a free wall hypokinesia and an estimated pulmonary systolic artery pressure of 55 mm Hg. The mitral valve was normal, and there was no intracardiac thrombus. A contrast maneuver revealed no interatrial defect. There was T-wave inversion on electrocardiography, and troponin level was 4.68 mmol/L. Coronary angiography showed the absence of obstructive coronary artery disease, which confirmed the diagnosis of TTC.FIGURE 1.: Echocardiogram showing a left ventricular apical ballooning. RV, right ventricle; RA, right atrium; LA, left atrium; LV, left ventricle; AB, apical ballooning.Because of the cardiac condition, heart-lung transplantation was considered. However, repeat echocardiographic evaluations showed rapid improvement of cardiac function, and the patient was suggested for urgent lung transplantation only. An organ was available 24 hr later. During the surgery, the patient was monitored with transesophageal echocardiography, which is our standard procedure during lung transplantation. Despite improved cardiac function, it was decided to use venous-arterial extracorporeal membrane oxygenation (ECMO) as soon as the procedure began. Sequential bilateral lung transplantation was performed uneventfully. ECMO was removed on the first postoperative day because echocardiography confirmed normal left ventricular function. The postoperative course was complicated by pulmonary infection and acute rejection; therefore, the patient was slow to wean from the ventilator, requiring tracheostomy on day 9 and ventilatory support for 11 days. The patient was discharged from the intensive care unit on postoperative day 17 and went home on day 34. The last echocardiographic examination performed a few days before hospital discharge showed a small and hyperkinetic left ventricle with a moderate dynamic obstruction of its outflow and normal right ventricle cavities. The same aspect was observed 2 months after. Comment TTC usually occurs after an intense negative emotional or physical stress (2). TTC can also be precipitated by severe intercurrent medical illness, exacerbated disorders, and procedural and perioperative stress. Organ transplantation is a stressful situation, and several cases of TCC have been published occurring during (3, 4) or after (5, 6, 7) liver transplantation. Physical and emotional stress was present in our patient: sepsis, end-stage respiratory failure with severe hypoxia and hypercapnia, mechanical ventilation, and urgent lung transplantation. All these factors could have triggered an intense release of catecholamines. In our case, rapid medical judgment could have led to contraindicate lung transplantation at least temporarily or to propose heart-lung transplantation. TTC was considered because of the typical echocardiographic morphologic feature in the absence of any known preexistent cardiac disease. Normal urgent coronary angiography was consistent with the diagnosis. Consequently, and as cardiac condition rapidly improved, the lung transplantation indication was confirmed, and the procedure was performed quickly because lungs were obtained rapidly. The surgical procedure was performed under ECMO to assist the left ventricle. This is, to our knowledge, the first reported case of TTC occurring in a patient awaiting urgent lung transplantation. In this case, rapid improvement allowed successful lung transplantation without the need for associated heart transplant. Mireille Michel-Cherqui1 Marie-Louise Felten1 Ngai Liu1 Edouard Sage2 Jérome Devaquet3 Dominique Grenet4 Marc Fischler1 1Department of Anesthesiology Hôpital Foch Suresnes, France 2Department of Thoracic Surgery Hôpital Foch Suresnes, France 3Department of Critical Care Hôpital Foch Suresnes, France 4Department of Pneumology Hôpital Foch Suresnes, France