Background
Takotsubo Cardiomyopathy (TCM) is characterized by left ventricular regional wall motion abnormalities, classically described as apical ballooning (atypical features such as midventricular, basal, or focal wall motion abnormalities also have been described) and triggered by emotional or physical stress. In this case, TCM was triggered by non-emotional stress, and eventually an unusual definite diagnosis was ascertained based on pathological specimen.
Case report
a 63-year-old woman presented to the emergency room complaining of 5 days of epigastric pain, nausea and emesis followed by chest tightness, dyspnea and diaphoresis. Physical examination was noticeable for abdominal pain with positive Murphy´s sign. ECG showed normal sinus rhythm, with T-wave inversion in DIII and aVF, and elevated troponin I. She also had leukocytosis and neutrophilia with normal liver function tests. Abdominal ultrasound showed a distended gallbladder with gallstones, without definitive evidence of cholecystitis. Accordingly, she was admitted to the Coronary Care Unit with suspected Non-ST elevation myocardial infarction.
Trans-thoracic echocardiogram (TTE) showed akinesia of all mid left ventricular segments with moderate systolic dysfunction -LVEF: 40%- (Figure 1A) suspicious for atypical TCM without a clear and identifiable emotional stress. Coronary angiography was negative for coronary stenosis and cardiac magnetic resonance (CMR) showed mid anterior and anterolateral segments dyskinesia, as well as mid septal, inferior and inferolateral segments akinesia (Figures 1B), with myocardial edema and no late gadolinium enhancement (Figure 1C), findings suggestive of TCM. Concomitant abdominal MRI demonstrated gallbladder distention, wall thickeningandedema, gallstones and peri-vesicular fat edema (Figure 1D).
Consequently, an infrequent type 2 (mid-ventricular) TCM, triggered by abdominal pain and inflammatory response due to acute cholecystitis, was diagnosed. Surgery was differed until full recovery of left ventricular function. One month later, after a full course of antibiotics and a new TTE showing no regional wall motion abnormalities (Figure 1E), a cholecystectomy was performed. Surprisingly, pathology revealed acute on chronic cholecystitis with eosinophilic infiltration, findings compatible with subacute cholecystitis (surgery performed 4 weeks after onset of symptoms). Currently, the patient is followed by Gastro-enterology for additional work-up.
Conclusion
We highlight the importance of multimodality imaging during diagnostic approach of atypical TCM. In this case, TTE findings in addition to a normal coronary angiogram, resulted in clinical suspicion of mid-ventricular TCM (present in 15% of cases) which was confirmed by CMR during the index event, followed by a normal TTE 4 weeks later. Cholecystitis is one of the multiple physical stressors, in addition to emotional triggers, causing TCM.
Abstract P1497 Figure.
