Takotsubo cardiomyopathy is described as a transient reversible cardiomyopathy that typically occurs in older women after emotional or physical stress [4]. The wall motion abnormality of Takotsubo cardiomyopathy usually extends to the territory comprising the coronary arteries, and it is typically described as apical ballooning due to apical akinesis or hypokinesis with preserved or hypercontractile basal segments [2]. The criteria used to diagnose Takotsubo cardiomyopathy have been described in detail by the Mayo Clinic [5], and it is essential to exclude significant organic stenosis or coronary artery spasm. Although women have a 9-fold higher risk of developing this cardiomyopathy when compared to men, women who are less than 55 years of age have a 5-fold risk reduction of developing the cardiomyopathy when compared to women who are older than 55 years of age [6]. Therefore, the case reported here was not at a common age for development of Takotsubo cardiomyopathy. However, given that there are several reports of Takotsubo cardiomyopathy developing perioperatively [7, 8], anesthesiologists must be prepared to provide appropriate management such as trans esophageal echocardiography and/or regional cerebral oxygen saturation monitoring. In approximately 85% of acute arterial embolism cases, occlusion is caused by emboli from a cardiac source [9], including atrial fibrillation associated with valvular heart disease or mural thrombi in an infarcted left ventricle. Therefore, the presence of cardiac thrombus should always be assessed to appropriately evaluate the source of acute arterial occlusion. It takes 2–5 days to develop thrombi after onset of Takotsubo cardiomyopathy [2], and acute leg pain was not the cause of Takotsubo cardiomyopathy.
Since our patient had stable vital signs without the use of catecholamines and since a typical wall motion abnormality such as apical ballooning extends across the territory of three vessels, and only modest elevation in cardiac troponin was observed as acute myocardial infarction, we did not perform coronary angiography. We found the gradual recovery of ventricular function by frequent TTE. Ten days after surgery, her ventricular function returned normal and Takotsubo cardiomyopathy was diagnosed without coronary angiography.
Left ventricular thrombus formation and cardioembolic complications are atypical findings in patients presenting with Takotsubo cardiomyopathy. Gregorio et al. and Heckle et al. examined the incidence of thrombus and embolic events in patients with Takotsubo cardiomyopathy and found it to be approximately 2.5–9.2 and 0.8–5.7%, respectively [10, 11]. Importantly, patients with left ventricular thrombi have an increased embolic risk and should be treated with anticoagulation [12]. Heckle et al. also recommended the start of anticoagulation therapy for patients with this type of cardiomyopathy [11]. Given that there can be a sudden rise in blood pressure, thought to be caused by the isolation of the left ventricular thrombus [13], proper management of hemodynamics is imperative during the perioperative and recovery period in Takotsubo cardiomyopathy.
Reports suggest that approximately 71% of Takotsubo cardiomyopathy patients have significant stressful events less than 48 h before the diagnosis is made [14].
In the present case, the patient was only aware of a significant stressful event when leg pain suddenly began. Takotsubo patients may not be identified, especially in emergency situations; therefore, the medical examiner should always keep in mind the presence of Takotsubo-related myopathies.
In addition, the patient’s oxygen saturation levels deteriorated during the perioperative period. We thought her relatively low oxygen saturation would be because of pain. There were no concerns about congestive heart failure, especially since this was an emergency operation in a healthy young woman. Furthermore, the recruitment maneuver performed during surgery improved her oxygenation levels and it appeared safe to conclude that her hypoxemia was due to the atelectasis from the severe pain she was experiencing. She did not complain severe pain after surgery, but her oxygen saturation was still low. We suspected pulmonary embolism, but TTE revealed severe left ventricular dysfunction (Fig. 3b, c); therefore, we concluded the desaturation was due to left ventricular failure. Nonetheless, special care is required in a patient with acute arterial occlusion, particularly because it can originate from a cardiac source and result in cardiac failure [9].
Oral contraceptives can decrease anticoagulant activity and promote a decrease in tissue plasminogen activator inhibitor and are known to be a risk factor for venous thromboembolism [15]. Although we could not find any inherited or secondary thrombophilia in this case, oral contraceptives might have contributed to formation of embolism.
