ACC0010.1177/2048872614521764European Heart Journal: Acute Cardiovascular CareBouabdallaoui et al.
EUROPEAN SOCIETY OF CARDIOLOGY ®
European Heart Journal: Acute Cardiovascular Care 2015, Vol. 4(2) 197–199 © The European Society of Cardiology 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/2048872614521764 acc.sagepub.com
Acute mitral regurgitation in Takotsubo cardiomyopathy Nadia Bouabdallaoui1, Zhen Wang1, Milena Lecomte1, Pierre V Ennezat2 and Didier Blanchard1
Abstract Takotsubo cardiomyopathy (TTC) is a well-recognised entity that commonly manifests with chest pain, ST segment abnormalities and transient left ventricular apical ballooning without coronary artery obstructive disease. This syndrome usually portends a favourable outcome. In the rare haemodynamically unstable TTC patients, acute mitral regurgitation (MR) related to systolic anterior motion (SAM) of the mitral valve and left ventricular outflow tract obstruction (LVOTO) is to be considered. Bedside echocardiography is key in recognition of this latter condition as vasodilators, inotropic agents or intra-aortic balloon counter-pulsation worsen the patient’s clinical status. We discuss here a case of TTC where nitrate-induced subaortic obstruction and mitral regurgitation led to haemodynamic instability. Keywords Takotsubo cardiomyopathy, left ventricular outflow tract obstruction, systolic anterior motion of the mitral valve Recieved: 20 October 2013 ; accepted: 29 December 2013
Case presentation An 88-year-old hypertensive female patient was admitted to our institution for the onset of an acute chest pain associated with inverted T waves on anterior leads on electrocardiogram (ECG) (Figure 1). Nitrates, enoxaparine and dual antiplatelet therapy were readily administered. Bedside echocardiography at admission revealed a large apical akinesia sparing basal segments without mitral regurgitation (Supplementary Material, Loop 1). A basal septal bulge measured at 16 mm was also displayed. During transfer to the cardiac catheterization laboratory (cath lab), severe hypotension developed. Heart auscultation revealed a previously undetected systolic murmur on the precordium. Repeat echocardiography showed severe mitral regurgitation (MR) related to a systolic anterior motion (SAM) of the mitral valve resulting in severe left ventricular outflow tract obstruction (LVOTO; maximal gradient 65 mm Hg; Figures 2 and 3; Supplementary Material, Loops 2 and 3). Nitrate infusion cessation and fluid challenge allowed for a rapid haemodynamic stabilisation with complete MR disappearance (Figure 3; Supplementary Material, Loop 4). Coronary angiography was normal while left ventricular (LV) angiography revealed apical ballooning (Supplementary Material, Loop 5) precluding diagnosis of myocardial infarction but suggestive of Takotsubo cardiomyopathy (TTC). Two days
later, normalisation of LV segmental wall motion and ejection fraction was documented on echocardiography. Troponin I levels rose to 2.5 ng/ml (normal