Takotsubo Cardiomyopathy with LVOT Obstruction Presenting as Heart Failure

Abstract

Background: Takotsubo cardiomyopathy is an acquired cardiomyopathy induced by stress, features similar to ST-elevation myocardial infarction. Less common but significant variant of TTC involves LVOT obstruction, which can lead to acute heart failure and hemodynamic instability. This report presents a case of TTC complicated by dynamic LVOT obstruction following a recent herpes zoster infection in an elderly female patient.

Case Report: We report a case involving an 81-year-old female patient with history of subtotal thyroidectomy and osteoporosis, who presented with acute chest pain. Electrocardiography revealed ST elevation in the inferolateral leads, and high-sensitivity troponin I levels were elevated. STEMI protocol was initiated, and urgent coronary angiography was done which showed non obstructive CAD. Transthoracic echocardiography and cardiac MRI were employed to assess ventricular mechanics, confirm the diagnosis. Management decisions were informed by hemodynamic and imaging findings.

Treatment and follow-up: Echocardiography indicated apical akinesia with preserved basal contraction, grade II systolic anterior motion of the mitral valve, turbulent left ventricular outflow tract with a peak gradient of 62 mmHg, moderate mitral regurgitation, and LVEF of 41%. The cardiac magnetic resonance findings were consistent with TTC. She was managed conservatively with beta-blockers, ARBs, and antivirals. Nitrates and inotropes were avoided to prevent exacerbation of LVOT obstruction. Serial electrocardiograms and troponin levels showed a decline, and the symptoms resolved. Patient was discharged with a plan for outpatient echocardiography in four weeks.

Conclusions: This case underscores the presentation of Takotsubo cardiomyopathy as ST-elevation myocardial infarction with dynamic LVOT obstruction in an elderly patient following physical stress, specifically herpes zoster. Early echocardiography is crucial for differentiating TTC from acute coronary occlusion when angiography reveals non-obstructive findings and for identifying LVOT obstruction. This necessitates the avoidance of nitrates and inotropes, while favoring beta-blockade. The continuation of beta-blocker therapy post-recovery may mitigate the risk of recurrence.