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Cardiogenic shock in a postoperative patient with neoplasia: what went wrong?

Session Clinical Case Corner 5 - Cardio-oncology pearls

Speaker Mariana Loredana Barbu

Event : Heart Failure 2019

  • Topic : heart failure
  • Sub-topic : Acute Heart Failure: Pathophysiology, Other
  • Session type : Clinical Case Posters

Authors : M L Barbu (Bucharest,RO), C Humulescu (Bucharest,RO), A Trandafir (Bucharest,RO), D Pasoiu (Bucharest,RO), R Ciomag (Bucharest,RO), C Homentcovschi (Bucharest,RO), A Gurghean (Bucharest,RO), D Spataru (Bucharest,RO), R Siliste (Bucharest,RO)

Authors:
M L Barbu1 , C Humulescu1 , A Trandafir1 , D Pasoiu1 , R Ciomag1 , C Homentcovschi1 , A Gurghean1 , D Spataru1 , R Siliste1 , 1Coltea Clinical Hospital - Bucharest - Romania ,

Citation:

Takotsubo cardiomyopathy is a rare stress-induced acute heart disease, which can manifest as severe left ventricle (LV) dysfunction. Data suggests that the underlying mechanism might be coronary spasm, induced by either the perioperative catecholamine storm, or by the anesthetics used in surgery, sometimes with a delay of a few days. Recent studies also show possible molecular correlations between neoplasia and this type of cardiomyopathy.

We present the case of a 48-year-old female patient, with a history of uterine cervical cancer for which she received surgical and radiotherapy treatment. One year later, a second intervention was performed, for occlusive syndrome in the setting of post-irradiation enteritis. While in the ICU, in the 48 hours after surgery, the patient developed dyspnea with orthopnea and anterior thoracic pain. The clinical exam shows tachycardia, LV gallop, pulmonary crackles, systemic congestion and hypotension, despite vasopressor support. Blood tests showed positive troponin levels and a high NT-proBNP.  The ECG revealed ST-segment elevation, while the echocardiography showed circumferential apical akinesia and severe LV systolic dysfunction with an ejection fraction of 25%. An emergency  angiography was performed, which did not find any coronary lesions. For the next 10 days, the patient’s condition improved constantly, with significant improvement of systolic function. As such, the final diagnosis was Takotsubo cardiomyopathy, triggered by the surgical intervention.

Our case had an association of all of the possible trigger factors (neoplasia, anesthesia, major surgery), which perhaps explains the severity of the disease in a patient with no previous cardiovascular disease.

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