Recurrent Tako-Tsubo cardiomyopathy with similar clinical and instrumental signs

Tako-tsubo syndrome is a clinical entity of transient left ventricular apical ballooning, frequently precipitated by a stressful event. The syndrome can be complicated by left ventricular outflow tract (LVOT) obstruction and can be recurrent. Herewe describe a case of a 64 years old female who had two episodes of tako-tsubo syndrome characterized by a similar stressful event and similar clinical and instrumental characteristics. Apical ballooning syndrome (or Tako-tsubo cardiomyopathy) is a clinical entity characterized by acute but rapidly reversible left ventricular (LV) systolic dysfunction. Recurrence of Tako-stubo syndrome is not frequent as well as LVOT obstruction, mitral regurgitation and shock. We describe a case of recurrent tako-tsubo cardiomyopathy with recurrence of LVOT obstruction and mitral regurgitation and complicated by cardiogenic shock. A 64 years old female with hypertension and chronic obstructive pulmonary disease (COPD) was admitted to the hospital in June 2005 with an acute recurrent chest pain. The patient was on cortisone from 24 h before because of an asthma exacerbation and she reported having also vomit and fright. The clinical symptom started in the morning but she had the first medical contact only in the evening. At the admission in intensive care unit (ICU) the patients was asymptomatic, the electrocardiogram (ECG) showed a 1.5 mm ST elevation from V3 to V6, DI, DII and aVL. Systolic blood pressure was 90 mm Hg, and an echocardiography exam showed an apical ballooning of the left ventricle with moderate mitral regurgitation secondary to left ventricular outflow tract (LVOT) obstruction (Fig. 1). Promptly, glycoprotein inhibitors and heparine were started and coronary angiography was performed the day after. Ventriculography confirmed the apical ballooning and normal coronary artery. Left ventricular ejection fraction (LVEF) was 35% (Fig. 2). The peak of plasma MB-creatinine kinase and of troponin I was 28.5 ng/mL and 6.9 ng/mL respectively. The systolic pressure remained stable at 90 mm Hg for four days with gradually recover until 110 mm Hg. The patient had no signs of congestive heart failure and was discharged after six days. Complete normalization of LVEF was documented at the follow-up. In December 2009 the woman was admitted in hospital for an exacerbation of her COPD. She was treated for eight days with cortisone, ipratropium, salmeterol and antibiotics with a good clinical response. During her stay she presented chest pain and the ECG showed a 2.5 mm STelevation fromV3 to V6, DI and aVL. The coronary angiography showed no obstructive coronary lesions and an apical ballooning aspect at the ventriculogram (Fig. 3). In ICU the patient developed a cardiogenic shock (initial systolic blood pressure of 90 mm Hg with rapid deterioration until 60 mm Hg). An urgent echocardiogram showed the apical ballooning with the concomitance of LVOT obstruction, systolic anterior motion of mitral valve and severe mitral regurgitation (Figs. 3 and 4). Peak dynamic intraventricular pressure gradient detected by echocardiography was 80 mm Hg. The LVEF was 25%. Urgently an intra-aortic balloon pump (IABP) was placed and then she was treated with low-dose beta-blockers until restoration of good pressure and initial recovery of LVEF. After a period of seven days the IABP was removed: the LVEF was 35% and the peak dynamic pressure gradient was lower (12 mm Hg). The peak of plasma MB-creatinine kinase and troponin T was 18.07 μg/L and 0.55 μg/L respectively. She was discharged after other eight days with a good pressure, no sign of congestive heart failure, a LVEF of 48% and absence of sign of LVOT obstruction and mitral regurgitation. Normalization of LVEF was after documented. Tako-tsubo syndrome, which is also called stress cardiomyopathy or transient left ventricular apical ballooning syndrome, is a clinical entity frequently precipitated by a stressful event. Initially, the syndrome was described in Japanese and afterwards an increasing number of cases has been reported also in Caucasian [1,2]. The main features are the absence of coronary atherosclerosis disease and the reversibility of left ventricular dysfunction. Recurrence of Tako-tsubo syndrome is not frequent. The yearly recurrence rate is 2.9% over the first few years, subsequently decreasing to 1.3% per year [3,4]. The syndrome can be also complicated by LVOT obstruction as previously described [5]. The report described is a rare case of recurrent Tako-Tsubo syndrome with recurrence of similar clinical and instrumental signs. In both episodes the main common findings were hypotension and an echocardiographic aspect of LVOT obstruction, systolic anterior motion and secondary mitral regurgitation. The recurrent episode was much more severe with a cardiogenic shock requiring the IABP positioning. Furthermore the patients experienced in both cases the same physical stressful event.