Q: 47 year old female is brought to ER with shortness of breath. She was always in good health but developed acute shortness of breath as she heard news of her son's death. Patient was sent for emergent CT scan with pulmonary embolism protocol which was reported negative but radiologist mentioned apical ballooning appearance of the left ventricle. Consistent with history your presumed diagnosis is "takotsubo" cardiomyopathy. As patient arrived to ICU what should be your first maneuver at bedside as you attempt to keep hemodynamics stable?



Answer: ECHOCARDIOGRAM


Echocardiogram should be performed as soon as possible in "takotsubo" cardiomyopathy not only to establish diagnosis but to rule out left ventricular outflow tract (LVOT) obstruction. Up to one fourth of patients in stress or "takotsubo" cardiomyopathy may develop LVOT due to apical ballooning of ventricle. Management entirely differs depending on presence or absence of LVOT in stress cardiomyopathy, popularly known as "takotsubo" cardiomyopathy.

Inotrope should be avoided in LVOT form of stress cardiomyopathy but may be useful in non-LVOT form of stress cardiomyopathy with frequent echo monitoring (as inotrope may convert non-LVOT to LVOT stress cardiomyopathy). 

 LVOT type stress cardiomyopathy may require fluid resuscitation in contrast to non-LVOT type which is treated more in usual fashion with heart failure treatment.



 References: 

 1. Villareal RP, Achari A, Wilansky S, Wilson JM. Anteroapical stunning and left ventricular outflow tract obstruction. Mayo Clin Proc 2001; 76:79.

2. Templin C, Ghadri JR, Diekmann J, et al. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med 2015; 373:929.

3. De Backer O, Debonnaire P, Gevaert S, et al. Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience. BMC Cardiovasc Disord 2014; 14:147. 

4. De Backer O, Debonnaire P, Muyldermans L, Missault L. Tako-tsubo cardiomyopathy with left ventricular outflow tract (LVOT) obstruction: case report and review of the literature. Acta Clin Belg 2011; 66:298.