A Case of Takotsubo Cardiomyopathy with ST Elevation during Total Arch Replacement

Kyoko Hayashida＊

Shinsuke Masuda＊

Kazuki Morimoto＊

(Department of Vascular Surgery, Maizuru Kyosai Hospital＊, Maizuru, Japan)

Aside from myocardial infarction, coronary spastic angina, and air embolism of the coronary arteries, Takotsubo cardiomyopathy is a rare cause of ST elevation during the perioperative period of cardiovascular surgery. Here we report a case of Takotsubo cardiomyopathy that developed with ST elevation during total arch replacement. A 71-year-old man was found to have an abnormality on chest X-ray. A thoracic aortic aneurysm with a maximum diameter of 68 mm was diagnosed on CT, and surgical intervention was indicated. Preoperative ECG showed no abnormality. Transthoracic echocardiography showed normal left ventricular wall motion. No valvular disease was observed. Coronary angiography showed a 50% stenotic lesion in the right coronary artery, but it was not considered significant. Total arch replacement was performed under moderate hypothermic circulatory arrest with anterograde selective cerebral perfusion. After retrograde terminal warm blood cardioplegia and aortic declamping while removing air from the root cannula, ST elevation in the II, III, and chest leads was noted and transesophageal echo showed impaired left ventricular wall motion. However, the right ventricular wall motion appeared normal under direct vision. While cardiopulmonary bypass was maintained with total perfusion, the ST level gradually improved. He was weaned from cardiopulmonary bypass 62 min after aortic declamping. ST elevation was observed again during sternal closure, so the patient was taken to the cardiac catheterization room immediately after the operation. Coronary angiography showed no significant change from before surgery. Left ventriculography revealed hypokinesia of the apex, leading to a diagnosis of Takotsubo cardiomyopathy. Inotropic agents and coronary dilators were discontinued. After confirming the stability of hemodynamics and the improvement of ST elevation on ECG, the patient was extubated on the first day after surgery and left the intensive care unit on the third day. On the 15th day, he was discharged from the hospital. This case shows that, if the right ventricular wall motion is normal despite ST elevation in the II and III leads intraoperatively, Takotsubo cardiomyopathy is a potential cause of the left ventricular dysfunction that might be considered in the differential diagnosis.

 

Jpn. J. Cardiovasc. Surg. 51: 308-313 （2022）

Keywords：Takotsubo cardiomyopathy; ST elevation; thoracic surgery