Cape Fear Valley Medical Center raeford, North Carolina, United States
Introduction/Purpose: Takotsubo Cardiomyopathy (TCM) was first described in Japan in 1990 by Dote and colleagues. The name "Takotsubo" was derived from the Japanese name of an octopus trap resembling the characteristic apical ballooning of the left ventricle on ventriculography. Other appellatives include "broken heart", "apical ballooning syndrome", "myocardial stunning", or "stress cardiomyopathy". The exact pathophysiology behind TCM is currently unknown. Postulated mechanisms for TCM include catecholamine excess, coronary artery vasospasm, microvascular dysfunction, and upregulation of certain cardiac genes. TCM is increasingly recognized among patients with cancer and is associated with adverse outcomes in this patient population. The potential triggers for TCM in cancer patients include the emotional turmoil of a cancer diagnosis, the inflammatory state of cancer itself, the physical stress of cancer surgery, systemic anti-neoplastic therapy, and radiation treatment.
Methods or Case Description: A 48-year-old premenopausal female with no significant medical or surgical history was evaluated after noting a dimple to the left breast. Pertinent family history was notable for colorectal carcinoma in maternal father and paternal grandfather, and first cousin. A diagnostic mammogram discovered a possible mass with architectural distortion in the left breast, lower inner quadrant. She subsequently underwent an ultrasound-guided biopsy of the left breast revealing a 1.7cm grade 2 infiltrating ductal carcinoma (IDC), ER-positive, PR-positive, HER-2 neu negative. The patient was clinically node-negative. When discussing surgical intervention, she chose to undergo a bilateral mastectomy with reconstruction instead of a lumpectomy with radiation to decrease the anxiety of other possible cancerous masses in the future.
Three weeks after her initial surgical consultation, the patient presented to the hospital to undergo a bilateral mastectomy with reconstruction. The patient was prepped and draped in the usual sterile fashion and was placed under general endotracheal anesthesia. Three minutes into the procedure while de-epithelizing the supraareolar crescent incision the patient abruptly went into asystole and CPR was initiated. After one round of CPR return of spontaneous circulation was achieved. The procedure was aborted and the patient awoke from anesthesia with no neurological deficits. A postoperative echocardiogram revealed an ejection fraction of 35-40% with global hypokinesis, right atrial dilation, and right ventricular enlargement. The patient's troponin level was elevated and peaked at 3.99. A CT angiogram of the chest did not show any evidence of a pulmonary embolism. A repeat echocardiogram was performed the following day revealing improved ejection fraction to 45%, moderate hypokinesis of the septum, mid-lateral wall, mid inferior wall with dilation, and hypokinesis of the apex suggestive of Takotsubo cardiomyopathy.
Cardiac catheterization was performed revealing no evidence of coronary artery disease (LAD 0%, circumflex 0%, RCA 0%). The next day the patient underwent bilateral breast wound closure and was discharged in stable condition. The following week, at an outpatient cardiology follow-up appointment, it was ultimately ruled that her cardiac episode was secondary to Takotsubo cardiomyopathy. Three weeks after the attempted mastectomy, the patient underwent a left lumpectomy and sentinel lymph node biopsy without incident.
Outcomes: Cardiac arrest in the operating theatre is a rare event with an incidence ranging from 1.1 to 34.6 cardiac arrests per 10,000 anesthetics. Patients with TCM present challenging and unexpected clinical scenarios as these patients can have no comorbidities or symptoms, like the case we described. In some cases, an acute emotional or physical stressor can be recognized as a triggering factor for Takotsubo cardiomyopathy. The diagnosis of a malignancy combined with the anxiety related to the incipient surgery and increasing pressure of work and modern life may trigger Takotsubo cardiomyopathy unexpectedly.
In young patients, physical stress rather than mental stress may trigger Takotsubo cardiomyopathy. Such stressors may include drugs, trauma, anesthesia, surgery, chronic pain, smoking, allergic reactions, high blood pressure, and asthma. If physical stressors are combined with mental stress, such as that caused by a cancer diagnosis, the combination may increase the likelihood of a cardiac arrest during a procedure. Whereas our cases had anesthesia and surgery, they were otherwise in good health and neither smoked nor took recreational drugs.
Vigilant psychological assessment should be included in case notes of all new patients with cancer. The literature does not provide sufficient evidence for a risk stratification approach or pre-treatment with beta blockers for patients with a high-stress score, but it does suggest the team (anesthetists and surgeons) should be more aware of warning signs and manage triggers with caution.
It is not possible to be certain whether a patient has Takotsubo cardiomyopathy in the acute intraoperative situation. Ventricular morphology with apical ballooning cannot immediately be assessed with a ventriculogram and echocardiogram. Patients have elevated cardiac enzymes and changes in the ECG similar to acute myocardial infarction (e.g. ST-segment elevation and T-wave inversion). Differential diagnosis in this situation includes segmental ventricular dysfunction to adrenaline administered according to the advanced life support protocol.
An analysis of the International Takotsubo Registry identified 1604 with TCM. patients with malignancy was observed in 267 (16.6%). The most frequent type of malignancy was breast cancer 26.2% (n=70), followed by tumors affecting the gastrointestinal system 16.1% (n=43), respiratory tract 15.4% (n=41), internal sex organs 14.6% (n=39), skin 13.1% (n=35), lymphatic system 7.1% (n=19), endocrine organs 6.7% (n=18), urinary tract 5.2% (n=14), and hematologic 3.0% (n=8) as well as the central nervous system 2.2% (n=6).
The syndrome has been observed most frequently in post-menopausal women who are exposed to major stressors. Patients can experience symptoms varying from chest pain (63%) to dyspnea on exertion (8%) and syncope (3%). This poses an added diagnostic challenge since this constellation of symptoms can mimic myocardial infarction (MI), pulmonary embolism, or cerebrovascular disorders.
Patients with malignancy not only have an increased risk for TCM development, but they also experience worse outcomes compared to patients with TCM in the absence of malignancy. Based on National Inpatient Sample (NIS) analysis study [84], TCM with coexisting malignancy had significantly higher mortality (13.8 vs. 2.9%, p < 0.0001), length of stay (7 vs. 4 days, p < 0.0001), and total charges ($29,291 vs. $36,231, p < 0.0001), compared to those with no malignancy. Thus, early recognition and prompt initiation of appropriate treatment may help lower mortality and reduce health care costs in these patients.
Conclusion: Takotsubo cardiomyopathy should be considered in any patient showing signs of significant perioperative stress who has a cardiac arrest or acute coronary syndrome like symptoms. Surgical teams should be aware of the importance of identifying emotional turmoil in their patients and how to counteract stress-induced cardiomyopathy.
