Inverted-Takotsubo Cardiomyopathy in a Patient with Pulmonary Embolism
A 38-year-old woman with no history of cardiac diseases or cardiac risk factors was referred to our emergency department because of chest discomforts, arrhythmia and shortness of breath after the surgery. A few days before she had fallen off the ladder and underwent surgery for right lateral malleolar fracture under spinal anesthesia. Physical examination revealed vital signs as follows: blood pressure 90/60 mm Hg, heart rate 75 beats/min, body temperature 36.7℃, respiratory rate 22/min and oxygen saturation 88% on room air. Oxygen saturation was increased to 94% after giving 3 L O2 via nasal prongs. The electrocardiogram (ECG) recording showed sinus rhythm, ST-segment depression in V3 through V5, and there were no typical features of ECG abnormalities associated with PE such as sinus tachycardia, S1Q3T3 pattern, complete and incomplete RBBB, and T wave inversion (). Chest radiography showed diffuse increased bronchovascular lung markings with mild congestion and edema, D-dimer was elevated to 1572 ng/mL (normal reference range 0-243 ng/mL) and altered results of the arterial blood gas analysis (pH 7.42/pCO2 25.8 mm Hg/pO2 69.7 mm Hg/HCO3 16.4 mmol/L) aroused suspicion of PE. It was confirmed by computed tomography and thus, therapy with heparin infusion was initiated (). Other laboratory findings indicated white blood cell counts of 10000/mm3; hemoglobin 9.7 g/dL; platelet count 275000/mm3; C-reactive protein 0.0 mg/dL; alanine aminotransferase 18 U/L; aspartate aminotransferase 39 U/L; total bilirubin 0.46 mg/dL; and serum creatinine 0.7 mg/dL. The cardiac enzyme levels were elevated with a peak level of creatine kinase-MB isoform 27 ng/mL (normal reference range 0-3.6 ng/mL) and troponin I 5.30 ng/mL (normal reference range 0-0.1 ng/mL). Transthoracic echocardiography showed hypokinesia of mid/base segments of LV with hypercontraction of apical segments and reduced ejection fractions estimated at 47% with no significant valvular dysfunctions. Right ventricular systolic dysfunction or dilated right ventricle was not found, and yet an estimated systolic pulmonary artery pressure increased mildly to 43 mm Hg on the assumption of right arterial pressure of 10 mm Hg (tricuspid regurgitation peak velocity: 2.87 m/s) (). Coronary angiography was immediately performed within an hour of admission and ruled out obstructive atherosclerotic diseases. She was managed with medical therapy using β-blocker and diuretics. Angiotensin converting enzyme inhibitors was not indicated because of mild hypotensions. After the medical treatment, the patient was presented free of symptoms for the following few days. Transthoracic echocardiography was undergone 1 week after her admission and showed improvements in ejection fractions of 58% with no wall motion abnormalities (). ECG was normalized within 10 days. The patient was discharged in good clinical conditions and remained well after 3 months of follow-up.