An Unexpected Presentation of Stress Cardiomyopathy

Background: Stress Cardiomyopathy (Takotsubo Cardiomyopathy) is a form of dilated cardiomyopathy that classically occurs in women, many of whom are postmenopausal. Typical signs include mild troponin elevation and ECG changes suggestive of anteroapical myocardial injury, even in the absence of significant coronary artery disease. Echocardiogram or ventriculography is required for diagnosis and most typically demonstrates a regional pattern of LV apical ballooning with relative sparing of contractile function at the base. The gold standard treatment is conservative therapy with incorporation of guideline directed medical therapy. Overall the prognosis is very good and often time will see resolution of their cardiomyopathy with time. In this case report, we discuss a very rare presentation of takotsubo cardiomyopathy making diagnosis and treatment challenging.

Case Presentation: A 62 year old female with a past medical history of essential hypertension, hyperlipidemia presented for constitutional symptoms including weakness, body aches. Patient underwent a CT of the chest and abdomen that incidentally discovered the patient to have situs inversus. Patients hospital course was remarkable for respiratory failure and subsequent PEA cardiac arrest. Successful return of spontaneous circulation was achieved and patient was found to have dynamic ST-elevations and a troponin that peaked at 7.98. Patient was emergently taken for left heart catheterization. Anatomical assessment was extremely challenging given patients rare anatomy however a pigtail catheter was utilized for a ventriculogram which revealed apical ballooning consistent with takotsubo cardiomyopathy. Patient underwent continued aggressive medical therapy and was ultimately dispositioned in stable condition.

Discussion: This case presentation demonstrates an extremely rare anatomic presentation in situs inversus. Situs Inversus is a rare but important genetic condition in which the organs of your chest and abdomen are positioned in a mirror image of the normal human anatomy. Although extremely rate, the operator must be prepared for all unique anatomical variants such as situs inversus in order to quickly define coronary anatomy and ventricular function in order to make appropriate medical decisions for your patients. Despite the complexity of the case the operator was able define the ventricular wall motion with a pigtail catheter that revealed classic apical ballooning motion. In addition as there was no significant disease appreciated in the coronary system this patient was given a diagnosis of takotsubo cardiomyopathy. This patient underwent conservative therapy with initiation of guideline directed medical therapy in which she tolerated well and was ultimately discharged from the hospital in stable condition. The patient was seen in the outpatient setting roughly three months later and underwent a repeat echocardiogram which revealed recovery of her ventricular function. This case demonstrates how patients will usually have recovery of their ventricular function with conservative therapy. In addition, despite the patients extremely rare anatomic orientation a diagnosis should still be made with utilization of ventriculography and assessment of coronary artery disease with coronary angiogram.