Syncope and cardiogenic shock in an 80-year-old woman

Accepted 20 January 2018 DesCripTion An 80-year-old woman presented with a 2-day history of breathlessness and syncope. Her medical history included Parkinson’s disease and a recent diagnosis of myelodysplasia for which she had undergone a (painful) bone marrow aspiration 2 days earlier. Presentation blood pressure (BP) was 69/38 mm Hg (and fell further to 59/40 mm Hg with impaired conscious level), heart rate 78, respiratory rate 17 and oxygen saturation 100% on air. Her presentation of ECG revealed anteroseptal Q waves with 1 mm ST segment elevation (figure 1). Emergency primary percutaneous coronary intervention was declined due to the probability of established myocardial infarction with consequent cardiogenic shock. Medical treatment and inotropic therapy with intra-aortic balloon pump (IABP) were directed. She underwent emergency portable echocardiography to understand the aetiology for cardiogenic shock. The panel of images (figure 2A–C) reveals evidence of basal hyperkinesia, systolic anterior motion (SAM) of the anterior mitral valve leaflet (causing left ventricular outflow tract obstruction (LVOTO)) and severe mitral regurgitation (MR) which was the cause of profound hypotension. There was coexistent apical ballooning/akinesia of the left ventricular apex consistent with a diagnosis of Takotsubo cardiomyopathy. A radial arterial line was inserted. Intravenous fluids combined with oral metoprolol (25 mg four times a day) resulted in gradual increase in systolic BP from 59 to 100 mm Hg over 12 hours. Repeat echocardiogram 72 hours later (figure 2D) revealed resolution of SAM and LVOTO with residual mild MR. Cardiac MRI (CMR) (figure 2E) 1 week after presentation revealed complete resolution of SAM, LVOTO and MR with no evidence of scarring or fibrosis, thus excluding myocardial infarction. Left ventricular function also had returned to normal (left ventricular ejection fraction >55%). Also, there was no evidence of proximal coronary artery occlusion on axial half-Fourier acquisition singleshot turbo spin-echo imaging. Haemodynamic instability characterised by SAM of themitral valve, LVOTO, severe MR and cardiogenic shock has previously been described in patients with Takotsubo's syndrome. 2 One of the largest series of Takotsubo cardiomyopathy described nine patients with LVOTO with marked reductions in gradients with intravenous esmolol. As far as we are aware, no previous description of dynamic LVOTO obstruction associated with Takotsubo has described BPs as low as in this case with altered conscious level. Second, the case is unique as it illustrates the rapidity of recovery with appropriate therapy. CMR confirmed absence of myocyte necrosis/infarction and complete resolution of SAM, LVOTO and MR and restoration of normal left ventricular systolic function within 7 days of presentation. Despite profound hypotension, this case highlights the effectiveness of beta blockade in reducing basal hyperkinesia and lessening LVOTO