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Tako-tsubo cardiomyopathy (stress-induced cardiomyopathy/broken heart syndrome) was first described in 1990 in Japan. It is a reversible cardiomyopathy characterised by rapidly reversible heart failure with transient left ventricular apical ballooning and transient systolic dysfunction presenting as acute coronary syndrome, but in the absence of significant coronary artery disease (1).

Case report

Conclusions

A case of unexpected sudden cardiac arrest: Tako-tsubo cardiomyopathy

Dr. Usha Gurunathan, Staff anaesthetist, The Prince Charles Hospital, Brisbane, Australia Email: usha.gurunathan@health.qld.gov.au.

1. Hessel EA, 2nd, London MJ. Takotsubo (stress) cardiomyopathy and the

anesthesiologist: enough case reports. Let's try to answer some specific questions! Anesthesia and analgesia 2010; 110: 674-9.

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3. Khallafi H, Chacko V, Varveralis N, Elmi F. "Broken heart syndrome": catecholamine surge or aborted myocardial infarction? J Invasive Cardiol 2008; 20: E9-13.

4. Lindsay J, Paixao A, Chao T, Pichard AD. Pathogenesis of the Takotsubo syndrome: a unifying hypothesis. Am J Cardiol 2010; 106: 1360-3.

5. Afonso L, Bachour K, Awad K, Sandidge G. Takotsubo cardiomyopathy: pathogenetic insights and myocardial perfusion kinetics using myocardial contrast echocardiography. Eur J Echocardiogr 2008; 9: 849-54.

6. Lau KC, Yiu KK, Lee KL, et al. A case of takotsubo cardiomyopathy: transient left ventricular apical ballooning. Hong Kong Med J 2006; 12: 388-90.

7. Madhavan M, Prasad A. Proposed Mayo Clinic criteria for the diagnosis of Tako-Tsubo cardiomyopathy and long-term prognosis. Herz 2010;35:240-3.

A 48-year old lady was scheduled to have cystoscopy and removal of urethral stent along with retrograde pyelogram as an elective procedure. She had undergone bilateral mastectomy in the past for her breast cancer and had subsequently been on treatment with tamoxifen. The patient also had chronic stress issues and depression. She had no known cardiac problems. On the day of surgery, following the application of standard monitoring, anaesthesia was induced through a 20 G cannula with a combination of propofol, fentanyl and midazolam. This was followed by insertion of size 4 laryngeal mask airway. Anaesthesia was maintained with oxygen, air and sevoflurane. The patient was positioned in lithotomy and was mechanically ventilated throughout the procedure. She was in sinus rhythm and was hemodynamically stable throughout the procedure. Just when the stent was being removed, normal sinus rhythm on the ECG had abruptly changed to a long pause followed by a single beat and asystolic cardiac arrest. Within a minute of CPR and adrenaline (up to 400 mcg), sinus rhythm returned with a heart rate of 46 per minute. On table trans thoracic echocardiogram revealed extensive akinesia of midventricular and apical segment with preservation of basal segments, moderate impairment of left ventricular systolic function with ejection fraction of 36% (see image). There was mild elevation of troponin and coronary angiogram was normal. A diagnosis of Tako-tsubo cardiomyopathy was made and patient was monitored in intensive care unit. Contrast echocardiogram, performed the next day showed some perfusion signal in apex suggestive of early stage of recovery. She was discharged with perindopril and bisoprolol. A repeat echocardiogram performed three months later, was found to be entirely normal (see image).

Although this condition is rare and unpredictable, caution should be exercised while managing the seemingly vulnerable group of patients, post menopausal women by minimising peri operative stressors.

Introduction Echocardiographic images

• Predominantly affects women of postmenopausal age with emotional or physical stress, presumably due to decreased oestrogen production (2) and due to increased catecholamine concentration. • ManyTako-tsubo cases reported in the perioperative period, with possible contribution from anxiety, fear, stress of intubation, pain from surgery. • Possible mechanisms: coronary artery spasm, microvascular dysfunction, impaired fatty acid metabolism within myocardium and myocardial stunning from catecholamine surge (3-5)

• Management essentially supportive including diuretics, vasodilators (6) • Usually spontaneous recovery within weeks • Recurrence of syndrome is also reported.

Discussion Bibliography

MAYO CLINIC CRITERIA FOR DIAGNOSIS OF TAKO-TSUBO CARDIOMYOPATHY (7)

1. Transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid segments with or without apical involvement; the regional wall motion abnormalities extend beyond a single epicardial vascular distribution; a stressful trigger is often, but not always, present* 2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture** 3. New electrocardiographic abnormalities (either ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin 4. Absence of: pheochromocytoma, myocarditis **There are rare exceptions