P072: A CASE OF STRESS INDUCED CARDIOMYOPATHY FOLLOWING INDUCTION OF GENERAL ANESTHESIA
Rahul Gupta, MD; Steven Minear, MD; Cleveland Clinic Florida
Introduction: Takotsubo Cardiomyopathy, or stress induced cardiomyopathy, is a cardiac syndrome of transient, reversible left ventricular dysfunction, particularly in the absence of significant coronary artery stenosis.
Case: In this case report, we examine a case of severe hypotension and bradycardia following induction of general anesthesia. Patient is a 73-year-old male with past medical history significant for hypertension, hyperlipidemia, and tongue SCC. Pre op EKG shows 1st degree AV block and echocardiogram showing a left ventricle ejection fraction (LVEF) of ~60%. Pt presented for laparoscopic inguinal hernia repair.
Following induction of general anesthesia, with 160 mg propofol, 100 mcg fentanyl, 50 mg rocuronium, and 100 mg lidocaine, patient developed severe bradycardia and hypotension, with HR dropping to the low 20s and MAPs below 50. Pt was intubated, with stimulus from intubation increasing the HR/BP. Patient, however, subsequently became bradycardic and hypotensive again. HR responded to glycopyrrolate and atropine boluses, followed by epinephrine boluses. Patient was briefly transcutaneously paced. After the emergent management of the bradycardia, transient sinus tachycardia developed with PVCs. Amiodarone bolus and drip were started to avoid further tachyarrhythmias, although they were later held given the HR began to trend back towards bradycardia. An arterial line and central line were established, with epinephrine and norepinephrine drips started to maintain MAPs >65. Patient was subsequently transferred to the Surgical ICU.
Repeat ECG revealed 2nd degree AV block, and labs were significant for elevated troponins. Troponin T was as high as 0.385. Repeat echocardiogram showed mid septal wall motion abnormality and a drop in LVEF to 47%. The left ventricle and left atrial cavity were found to be mildly dilated as well. Pt was started on a heparin drip, oral aspirin, atorvastatin, and clopidogrel.
Patient was taken for a left heart catheterization, showing non obstructive CAD, and was therefore given a diagnosis by the consulting cardiologist of mid cavitary stress induced cardiomyopathy in the context of surgical stress.
Patient underwent implantation of a dual chamber pacemaker and was discharged in a stable cardiovascular condition, with discontinuation of heparin and clopidogrel. Patient was scheduled for outpatient follow up with cardiology. Cardiac stress testing 10 days after the inciting event showed a return of LVEF to 62%, no left ventricular regional abnormality, and no perfusion defects.
Discussion: The most widely accepted diagnosis criteria for takotsubo cardiomyopathy were published by the Mayo Clinic in 2004, with additional criteria being added in subsequent years. It is most commonly described as a syndrome of unknown etiology with acute dilation of the left ventricle with normal epicardial coronary arteries. Initial treatment involves heparin, aspirin, and beta blockers. Anticoagulation is important to prevent left ventricular thrombosis and embolic events. Most patients show significant improvement of systolic function within a week, and full resolution within 12 weeks of onset. While the pathophysiology is unclear, the most supported theory is catecholamine-induced cardiotoxicity and microvascular dysfunction. This case highlights how takotsubo cardiomyopathy should be considered in the differential for a potential acute coronary syndrome in the perioperative period.