Perioperative Takotsubo Cardiomyopathy: A Systematic Review of Published Cases

Abstract

Takotsubo cardiomyopathy (TCM) is a condition that is characterized as a transient ventricular dysfunction in the absence of obstructive coronary artery disease (CAD) and is usually triggered by an acute medical illness or intense physical or emotional stress. Multiple cases of perioperative TCM (pTCM) have been reported from around the world, but a qualitative analysis of these cases has not yet been done. For this systematic review, we searched PubMed for case reports and case series of pTCM published from 1966 to April 2015 with the objective being to evaluate whether differences in demographics, clinical features and outcomes exist between pTCM and nonperioperative (npTCM), as well as to attempt to identify any predictors of the severe form of pTCM, which requires mechanical circulatory support (MCS) devices or leads to death. A total of 93 articles describing 102 cases were retrieved and reviewed. The findings were compared with the analysis of the International Takotsubo Registry by Templin et al and a systematic review of mainly non-perioperative TCM (npTCM) by Gianni et al. Although we were unable to identify definitive risk factors for pTCM, our review suggests that pTCM appears to occur in younger patients and with a lower likelihood of ST segment elevations and T-wave abnormalities than in npTCM. No demographic or clinical factors were identified that were predictive of more severe outcomes. As TCM in general can be a life-threatening event, it would therefore be prudent to consider pTCM within a differential diagnosis in any patient who decompensates in the perioperative period.

Takotsubo cardiomyopathy following resection of a fourth ventricle tumour

“…Takotsubo cardiomyopathy may present in the peri‐operative period in a myriad of ways including pulmonary oedema, ECG changes, elevation of cardiac enzymes, hypotension, cardiogenic shock or cardiac arrest . The two most commonly described symptoms are acute substernal chest pain and dyspnoea, both being described on emergence . In our case despite our initial concerns of the potential for myocardial dysfunction, we were falsely reassured by the physiological stability in the immediate postoperative phase.…”

“…Takotsubo cardiomyopathy is a rare disorder, and although the exact prevalence is unknown, estimates suggest the frequency to be 5.2 and 0.6 per 100,000 for women and men, respectively, with 30% of these relating to an in‐hospital surgery or procedure . The major pathophysiological phenomenon is a disproportionate catecholamine discharge in response to stress, therefore exaggerated anxiety about surgery or anaesthesia , a light plane of anaesthesia, insufficient analgesia and surgical pain or stimulus have all been suggested to be inciting factors .…”

“…If pharmacological support is required, exogenous catecholamine use during acute cardiogenic shock could theoretically worsen the cardiomyopathy. Therefore, some suggest severe cases may benefit from early institution of temporary mechanical support devices such as intra‐aortic balloon pump, extracorporeal membrane oxygenation or temporary ventricular assist devices , but these require local expertise and may necessitate anticoagulation. Milrinone as a non‐catecholamine inotropic drug may have a role, as may levosimendan .…”

“…There are no controlled data to define an optimal medical regimen, but it seems reasonable to treat these patients with the standard medications that are used for left ventricular systolic dysfunction, including β‐adrenergic antagonists, angiotensin‐converting enzyme (ACE) inhibitors and diuretics. Medications such as β‐blockers are often advocated to counteract the hyper‐catecholamine state, while ACE inhibitors or angiotensin receptor blockers may improve survival at 1 year .…”

“…Published reports of takotsubo cardiomyopathy complicating the peri‐operative pathway from induction to the postoperative period exist in a range of surgical specialities including general surgery, orthopaedics, obstetrics and gynaecology and neurosurgery . However, it is still sufficiently rare that these are reported primarily as case reports.…”