A 73-year-old woman with a past medical history significant for 55 pack/year cigarette smoking and hypertension was admitted for evaluation of a right lower lobe pulmonary nodule. The patient had a bronchoscopy, mediastinoscopy, and right thoractomy with resection of the right lower lobe, which revealed non-small cell lung carcinoma. Post-operative course was unremarkable until day 6 when the patient developed acute onset of shortness of breath and chest pain. On physical examination, the patient was hypotensive, tachycardic and had new findings of jugular venous distention and an S3 gallop. Chest film showed new bilateral pleural effusions with superimposed bilateral infiltrates. Arterial blood gas on room air revealed a ph 7.53, pCO2 25, pO2 41, and HCO3 21. Electrocardiogram showed sinus tachycardia with a new left bundle branch block. Peak cpk and troponin were 509 IU and 1.47 ng/mL, respectively. An echocardiogram showed an ejection fraction of 10% with global hypokinesis. Emergent coronary angiography revealed no significant obstructive coronary artery disease, akinesis in the apical segments, and hyperkinesis in the basal segments. Within 24 hours, a repeat echocardiogram indicated an ejection fraction of 50% with no wall motion abnormalities. Repeat electrocardiogram showed normal sinus rhythm with no evidence of left bundle branch block. Lower extremity Doppler sonograms indicated no evidence of deep venous thrombosis. Follow-up echocardiogram, obtained 7 days after the acute event, revealed complete resolution of ventricular dysfunction with an ejection fraction of 59% and normal wall motion. The differential diagnosis of transient left ventricular dysfunction in this case includes sepsis-induced myocardial depression, fulminant myocarditis, and a syndrome termed “Tako-Tsubo” cardiomyopathy. The most convincing evidence against the diagnoses of sepsis-induced myocardial depression or fulminant myocarditis lies in the very rapid normalization of ventricular function. The findings in this case are most consistent with the features of “Tako-Tsubo” cardiomyopathy, as described by Akashi et al. These include women > 60 years with no known history of coronary artery disease, sudden onset of signs and symptoms similar to an acute myocardial infarction, reversible ventricular dysfunction defined as apical akinesis and basal hyperkinesis, and a rapid resolution seen within days to weeks. Although the suggested etiology is thought to be based on a catecholamine induced mechanism, further studies are needed to confirm the instigating factors leading to this newly recognized cardiomyopathy.
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