Abstract
Takotsubo cardiomyopathy (TCMP) is characterized by transient and reversible left ventricular regional wall motion abnormalities triggered by acute and intense emotional or physical stress. We present a case of a 79 year old woman with a hypertensive crisis after microwave ablation (MWA) for metastatic liver lesions. Initial evaluation suggested an acute coronary syndrome with an ST segment elevation and with elevated serum troponin T. No associated chest pain or dyspnea was present. Further evaluation with ECG, echocardiography, coronarography with left ventricle angiogram and MRI was consistent with an apical ballooning syndrome. She was managed medically and the abnormalities resolved in the next 8 weeks during her follow up. The association between MWA and TCMP has been only reported once in the literature. We would like to emphasize one of the risks of MWA in or near the thoracic region potentially leading to TCMP.
Highlights
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Takotsubo cardiomyopathy is characterized by transient and reversible left ventricular regional wall motion abnormalities triggered by acute and intense emotional or physical stress.
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Here we present a case of Takotsubo CMP after microwave ablation for liver metastasis.
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It is an unusual complication of MWA: as far as we found in Pubmed only one comparable case had been published.
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Introduction
Takotsubo or stress cardiomyopathy (CMP) is characterized by transient and reversible left ventricular regional wall motion abnormalities, which may be triggered by an acute and intense emotional or physical stress. We present a case of Takotsubo cardiomyopathy after microwave ablation for liver metastasis.
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Case report
A 79-old female patient with a history of systemic hypertension, hypercholesterolemia, obesity and recto-sigmoid carcinoma was hospitalized for a microwave ablation (MWA) of metastatic liver lesions. The sigmoid tumor was resected two year earlier, followed by chemotherapy. One year after surgery, she developed two large liver lesions, which were treated by radiofrequency ablation (RFA) and additional chemotherapy (Capacetabine, Xeloda®). She was now hospitalized for an MWA of a new liver metastasis. The duration of ablation time was 27 min. The pre-procedure-ECG showed discrete, horizontal ST depression and T wave abnormality in the anterolateral leads. After the MWA she was transferred to the post-operative care unit for observation. Upon awakening she developed severe hypertension (228/115 mmHg), which initially was treated with urapidil 5 mg, without immediate response. A continuous infusion of nicardipine – titrated to 2.5 mg/h – was started, which subsequently normalized BP. During further continuous monitoring ST- and T-changes were noticed. A 12-lead ECG showed sinus rhythm (68 bpm) and ST elevation in leads V2–V4. The patient only complained of nausea. A first blood sample showed elevated cardiac troponin T 0.114 μg/l (normal <0.015 μg/l). An urgent transthoracic echocardiography (in dorsal decubitus) showed no pericardial effusion and an apparently normal left ventricular regional contractility (apical and parasternal long axis view). In the parasternal short axis view, only the apex, antero-septal and inferior regions were visualized. A second ECG, taken two hours later, showed biphasic T waves and deep T wave inversion in leads I, aVL and the precordial leads V2 to V6. Furthermore, there was important prolongation of QT (QTc 531 ms) ( Fig. 1 ). Cardiac troponin T reached a maximal level of 0.426 μg/l. The first diagnosis was an acute coronary syndrome, type non-STEMI. The patient was admitted to the coronary care unit for further monitoring. Cardiac catheterization was done the next day. The angiogram showed normal coronary arteries. On the other hand, left ventriculography demonstrated a broad akinetic apical region ( Fig. 2 ). Transthoracic echocardiography at day 1 showed apical akinesia and a mild to moderate decreased LV systolic function (EF 40%–45%). At day 5 MRI of the heart was performed, which showed persistent akinesia of the apical region. There was no delayed enhancement on T2-weighed images. These findings are compatible with Takotsubo CMP.
