Cardiogenic Shock Secondary To Reverse Takotsubo Associated With Buprenorphine Precipitated Withdrawal
Presenter
David A. Power, MD, Icahn School of Medicine at Mount Sinai, New York City, NY
David A. Power, MD1, Anelechi Anyanwu, MD1, Shinobu Itagaki, MD1, Umesh Gidwani, MD, FSCAI2, Sumeet Mitter, MD1, Annapoorna S. Kini, M.D.3 and Gregory Serrao, MD, FSCAI4, (1)Icahn School of Medicine at Mount Sinai, New York City, NY, (2)Icahn School of Medicine at Mount Sinai, Demarest, NJ, (3)Mount Sinai Hospital, New York, NY, (4)Icahn School of Medicine at Mount Sinai, New York, NY
Learning Objectives:
- Identify reverse Takotsubo cardiomyopathy
- Understand the unique pathophysiology and management of cardiogenic shock complicating Takotsubo syndrome
Keywords: Cardiogenic Shock and Hemodynamic Support
Background:
Providing hemodynamic support for patients with Takotsubo cardiomyopathy and cardiogenic shock can be challenging. Inotropic medications may potentiate the inciting catecholamine surge, worsen mid-cavitary left ventricular obstruction and the appropriate mechanical support options remain undefined. We report the case of a patient with buprenorephine precipitated opioid withdrawal who developed reverse Takotsubo syndrome (R-TTS) and cardiogenic shock (CS) requiring microaxial partial left ventricular support for full recovery.
Case Methods:
A 26 year old male with a medical history of opioid misuse presented to the emergency room with abdominal pain and vomiting. Vital signs revealed hypotension 70/30mmHg, heart rate 140 bpm, tachypnea and SpO2 74%. Repeat lab testing demonstrated Troponin-I 17.5ng/mL, lactate 5.1mmol/L, leukocytosis and elevated transaminases. ECG showed anterior ST-segment elevation. Transthoracic echocardiography revealed severe left ventricular dilatation, LV ejection fraction (LVEF) of 19%, and preserved apical cap function. Coronary angiography demonstrated normal coronary arteries with elevated LV filling pressures (25 mmHg), cardiac output 3.1L/min with a cardiac power output of 0.55. A multi-disciplinary shock team discussion was conferred and a preliminary diagnosis of R-TTS was made. The patient was taken to the operating room for implantation of micro-axial partial LV support with Impella 5.5 (Abiomed, Danvers MA). The patient was admitted to the cardiac intensive care unit and catecholamine vasopressors were rapidly weaned. At time of discharge on Day 10 a TTE showed normal biventricular size, LVEF 50% and normal right ventricular function.
Results
and
Conclusions
Our case demonstrates novel aspects of cardiogenic shock management in R-TTS. First, upon diagnosis we decided to administer a phosphodiesterase-3 inhibitor to avoid the use of catecholamines. Second, we used an Impella as a bridge to recovery given persistent CS, preserved right ventricular function, and a projected short LV recovery time. Overall, there is a lack of quality evidence regarding the management of patients with Takotsubo cardiomyopathy related CS.