Miocardiopatia Takotsubo: estado da arte

Anaesthetic management of large meningioma excision complicated by Takotsubo and posterior reversible encephalopathy

A 47-year-old woman with a history of a pulsatile headache, photophobia, dizziness and blurred vision was diagnosed with a massive expansive meningioma and proposed for surgical excision. During surgery, the patient began to show progressive haemodynamic instability with extreme hypotension and severe arrhythmia that only responded to epinephrine. With the continuity of haemodynamic instability, ST segment elevation and great amount of blood loss, the surgery was postponed. The follow-up brain CT scan showed evidence of posterior reversible encephalopathy syndrome and cardiac catheterisation diagnosed as Takotsubo syndrome. The patient remained sedated under aminergic support and was admitted to a cardiac intensive care unit. After clinic stabilisation, the patient underwent two more surgical procedures with special attention paid to monitoring haemodynamic stability, blood loss and cardiac output. After 70 days of admission, the patient was discharged with moderate visual impairment and follow-up consultations in neurosurgery and cardiology.

Inverted Variant of Takotsubo Syndrome Caused by Inhaled Adrenergic Beta-2 agonists

Takotsubo syndrome (TS) is an acute and reversible clinical syndrome characterized by transient hypokinesis of the left ventricular (LV) apex. Variant forms of LV dysfunction have been reported, including inverted Takotsubo syndrome (ITS), which represents only 5% of cases and has previously been linked to excessive use of inhaled adrenergic beta-2 agonists. The authors describe the case of a 60-year-old female patient who was diagnosed with ITS after the excessive use of inhaled adrenergic beta-2 agonists. This case highlights an uncommon variant of this syndrome that may not be obvious and must be suspected in this particular context.

Mourning and Takotsubo cardiomyopathy: neuroendocrine implications and nutritional management

This article aims to make reference to some recent mourning aspects considered risk factors for cardiovascular disease, specifically the Takotsubo cardiomyopathy. The objective was to describe the stress from the death of a loved one combining it to the possibility of occurrence of Takotsubo cardiomyopathy through the perception of a traumatic event by the cortex, which triggers the subcortical brain circuit affecting the endocrine response. Given the growing acknowledgement of this cardiomyopathy, it is possible to contextualize the nutritional behaviours and decisions surrounding it, whose benefits must exceed the condition of temporary cardiac dysfunction and extend to food choices that have some influence in the limbic system. It is a descriptive analysis that aims to problematize the theme into reflections based on this experience, considering the foundation with the science of nutrition.

Stunned myocardium after an anesthetic procedure in a pediatric patient - case report

Takotsubo syndrome (TTS) is an acquired transient type of systolic dysfunction which mimics myocardial infarction clinically and electrocardiographically. TTS is also known as stress cardiomyopathy, broken heart syndrome, apical ballooning, reversible acute heart failure, neurogenic stunned myocardium or acute catecholamine cardiomyopathy. This case report describes an uncommon presentation of myocardial stunning after an anesthetic procedure. A 14-year-old girl with a history of pineal cyst and hemiplegic migraine was admitted for control brain magnetic resonance imaging. During anesthesia induction with propofol she suffered bradycardia, which was reversed with atropine, followed by tachyarrhythmia, reversed with lidocaine and precordial thump. Within hours she developed pulmonary edema and global respiratory failure due to acute left ventricular dysfunction. A transthoracic echocardiogram showed a dilated left ventricle with global hypokinesia and depressed left ventricular systolic function (ejection fraction <30%). The electrocardiogram showed persistent sinus tachycardia and nonspecific ST-T wave abnormalities. Cardiac biomarkers were elevated (troponin 2.42 ng/ml, proBNP 8248 pg/ml). She was placed on diuretics, angiotensin-converting enzyme inhibitors, digoxin and dopamine. The clinical course was satisfactory with clinical, biochemical and echocardiographic improvement within four days. Subsequent echocardiograms showed no ventricular dysfunction. The patient was discharged home on carvedilol, which was discontinued after normalization of cardiac function on cardiac magnetic resonance imaging. Few cases of TTS have been described in children, some of them triggered by acute central nervous system disorders and others not fulfilling all the classical diagnostic criteria. In this case the anesthetic procedure probably triggered the TTS.

[Perioperative approach of patient with takotsubo syndrome]

INTRODUCTION

Takotsubo cardiomyopathy (TCM) is a stress-induced cardiomyopathy. It is characterized by an acute onset of symptoms and electrocardiographic abnormalities mimicking an acute coronary syndrome in the absence of obstructive coronary artery disease. Any anesthetic-surgical event corresponds to a stressful situation, so the anesthetic management of patients with TCM requires special care throughout the perioperative period. We describe the anesthetic management of a patient with a confirmed diagnosis of TCM undergoing segmental colectomy.

CASE REPORT

Female patient, 55 years old, ASA III, with history of takotsubo syndrome diagnosed 2 years ago, scheduled for segmental colectomy. The patient, without other changes in preoperative evaluation, underwent general anesthesia associated with lumbar epidural and remained hemodynamically stable during the 2hours of surgery. After a brief stay in the Post-Anesthesia Care Unit, she was transferred to the Intermediate Care Unit (IMCU), with epidural analgesia for postoperative period.

CONCLUSION

TCM is a rare disease which true pathophysiology remains unclear, as well as the most appropriate anesthetic-surgical strategy. In this case, through a preventive approach, with close monitoring and the lowest possible stimulus, all the perioperative period was uneventful. Because it is a rare disease, this report could help to raise awareness about TCM.

A rare case of concomitant stress (takotsubo) cardiomyopathy and acute myocardial infarction

Stress cardiomyopathy and myocardial infarction are generally regarded as mutually exclusive diagnoses. We report the case of a 54-year-old woman who presented with acute chest pain. Her echocardiogram and ventriculography were typical of stress cardiomyopathy, but she had one subocclusive coronary lesion, a highly significant rise in troponin and a subendocardial myocardial infarction scar documented on cardiac magnetic resonance. This is a rare case of concomitant myocardial infarction and stress cardiomyopathy, in which the acute coronary syndrome itself may have been the stressor, given the absence of other identifiable causes.

Apical ballooning syndrome: a case report

Background

Apical ballooning syndrome mimics acute coronary syndromes and it is characterized by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis.

Case presentation

This is a case of a 40-year-old Caucasian male without any health related problems that was submitted to an urgent coronary angiography because of acute chest pain and marked precordial T-wave inversions suggestive of acute myocardial ischemia. Coronary angiography showed no significant stenosis of the coronary arteries. Left ventriculography showed systolic apical ballooning with mild basal hypercontraction.

Conclusion

Physicians should be aware of the presentation of apical ballooning syndrome, and the chest pain after following acute stress should not be readily attributed to anxiety.