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Beth Israel Deaconess Medical Center, Boston, MA
INTRODUCTION:Transient left ventricular (LV) failure without coronary artery stenosis is known as Takotsubo Syndome. It occurs following intense emotional or physical stress and simulates the clinical presentation of an acute myocardial infarction. We report a case of transient LV failure following therapeutic rigid bronchoscopy.
CASE PRESENTATION:A 77-year-old man with recurrent esophageal adenocarcinoma and good performance status presented with increasing dyspnea and cough. He had complete left sided atelectasis due to left main stem obstruction. The patient was afebrile, normotensive, with an oxygen saturation of 94% on 6 liters. Physical exam was remarkable for dullness and decreased breath sounds over the left hemithorax. White blood cell count was 13,000 with normal differential. Electrocardiogram revealed chronic left bundle branch block. Rigid bronchoscopy under general anesthesia and jet ventilation was performed and mechanical destruction of the tumor with the microdebrider was performed followed by deployment of a metallic covered stent with excellent result.The patient was extubated in the operating room and transferred to the recovery unit. Thirty minutes later, while using the urinal the patient developed acute respiratory distress, severe hypoxemia and hypertension followed by hypotension. The patient was intubated and flexible bronchoscopy showed a patent stent. Echocardiography revealed a normal RV, severely depressed LV with ejection fraction 15%, and septal-anterior-apical wall akinesis. Chest radiograph: showed bilateral alveolar infiltrates. EKG: unchanged . Pulmonary Artery Catheter: PCWP : 35 , SVR 1400, CI 1.5. Emergent coronary angiography revealed no significant coronary artery disease and but severe LV dysfunction. An intraaortic balloon pump (IABP) was placed for cardiogenic shock. The IABP was discontinued at 24hrs and the patient was off pressors and extubated at 48hrs. Seventy-two hours later, repeat echocardiogram showed significant improvement of the LV systolic function with an ejection fraction of 45% with hypokinesis of the septum and apex. Patient was discharge home with home oxygen in stable condition.
DISCUSSIONS:This is the first description of Takotsubo Syndrome after therapeutic bronchoscopy. The patient experienced cardiogenic shock in the absence of other obvious underlying explanations and fully recovered with maximal symptomatic support. The mechanism(s) responsible for the development of transient left ventricular apical akinesis remain elusive. Proposed etiologies include coronary artery spasm, myocarditis, and dynamic mid-cavity obstruction related to catecholamine excess. While the incidence of this disorder is still unknown, it is plausible that it is higher than previously thought given its resemblance to acute myocardial infarction.
CONCLUSION:The increasingly recognized Takotsubo Syndrome should be considered as a possible etiology for patients with cardiogenic failure after therapeutic bronchoscopy in the absence of other underlying etiologies.
DISCLOSURE:Jorge Guerrero, No Financial Disclosure Information; No Product/Research Disclosure Information
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