Scientific Letter
Extracorporeal membrane oxygenation support for Takotsubo syndrome and long QT after cardiac surgery
Soporte con oxigenación de membrana extracorpórea en un síndrome de Takotsubo y QT largo tras cirugía cardiaca
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García-Delgado, D. García-Huertas, I. Navarrete-Sánchez, L. Olivencia-Peña, J.M. Garrido" "autores" => array:5 [ 0 => array:4 [ "nombre" => "M." "apellidos" => "García-Delgado" "email" => array:1 [ 0 => "mjgardel@hotmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "D." "apellidos" => "García-Huertas" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Navarrete-Sánchez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "L." 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"apellidos" => "Garrido" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] ] "afiliaciones" => array:2 [ 0 => array:3 [ "entidad" => "Unidad de Cuidados Intensivos, Complejo Hospitalario Universitario de Granada, Granada, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Cirugía Cardiaca, Complejo Hospitalario Universitario de Granada, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Soporte con oxigenación de membrana extracorpórea en un síndrome de Takotsubo y QT largo tras cirugía cardiaca" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 913 "Ancho" => 2000 "Tamanyo" => 291630 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Twelve-lead electrocardiographic tracing corresponding to day two after onset of the condition, with a QTc interval of 680<span class="elsevierStyleHsp" style=""></span>ms. (B) Electrocardiogram corresponding to evolutive day 10, showing a QTc interval of 475<span class="elsevierStyleHsp" style=""></span>ms, but with persistent T-wave inversion.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Takotsubo syndrome is a type of myocardiopathy characterized by transient left ventricular dysfunction associated to electrocardiographic changes similar to those of acute myocardial infarction, though without evidence of coronary disease, and with scantly altered myocardial enzyme levels. The syndrome is also known as transient apical dysfunction, “apical ballooning” or stress-induced myocardiopathy, since it generally affects postmenopausal women following some stressing event. The diagnostic criteria of Takotsubo syndrome are: acute electrocardiographic anomalies such as ST-segment elevation or T-wave inversion; the absence of obstructive coronary disease; akinesia or transient dyskinesia of the left ventricle; and the absence of traumatic brain injury, intracranial hemorrhage, pheochromocytoma, myocarditis or hypertrophic myocardiopathy.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">1</span></a> The incidence and prevalence of the syndrome are not known, and few cases have been reported in patients subjected to cardiovascular surgery. We present the case of a woman operated upon due to an atrial myxoma, who in the postoperative period developed cardiogenic shock secondary to Takotsubo syndrome.</p><p id="par0010" class="elsevierStylePara elsevierViewall">A 68-year-old woman with arterial hypertension and non-insulin dependent diabetes reported to the emergency service due to clinically manifest heart failure for the last two weeks. Upon admission she presented resting dyspnea and palpitations. Rapid atrial fibrillation was detected, requiring pharmacological cardioversion. The echocardiographic study (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) revealed a large left atrial mass (1.8<span class="elsevierStyleHsp" style=""></span>×<span class="elsevierStyleHsp" style=""></span>7<span class="elsevierStyleHsp" style=""></span>cm in size) protruding toward the left ventricle and causing secondary mitral valve stenosis and atrial dilatation, with a preserved left ventricular ejection fraction (LVEF). Preoperative coronary angiography showed no lesions.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">Surgery was performed four days later, with trans-septal removal of the myxoma. There were no relevant incidents other than a tendency toward hypoxemia. The clamping and extracorporeal circulation times were 52 and 83<span class="elsevierStyleHsp" style=""></span>min, respectively. Intraoperative echocardiography confirmed the absence of any remnant myxoma tissue, with a normal LVEF. The patient remained stable and subjected to mechanical ventilation during her first hours of stay in the Intensive Care Unit (ICU) due to the aforementioned hypoxemia, with FiO<span class="elsevierStyleInf">2</span><span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>0.6 and PEEP<span class="elsevierStyleHsp" style=""></span>=<span class="elsevierStyleHsp" style=""></span>10–12<span class="elsevierStyleHsp" style=""></span>cmH<span class="elsevierStyleInf">2</span>O. Eight hours after surgery she suffered a sudden hypertensive crisis (systolic blood pressure >220<span class="elsevierStyleHsp" style=""></span>mmHg) followed by hypotension and cardiac arrest with pulseless electrical activity (electromechanical dissociation). Resuscitation maneuvering restored the pulse within a few minutes. The patient was in cardiogenic shock refractory to high-dose vasoactive medication (adrenalin, dobutamine, noradrenalin); as a result, venous-arterial extracorporeal membrane oxygenation (V-A ECMO) was therefore finally decided.</p><p id="par0020" class="elsevierStylePara elsevierViewall">Transthoracic echocardiography revealed severe left ventricular dysfunction (LVEF<span class="elsevierStyleHsp" style=""></span><<span class="elsevierStyleHsp" style=""></span>20%), hyperdynamic basal segments and akinesia of the middle and apical segments–these findings being typical of Takotsubo syndrome. There were no significant cardiac enzyme elevations over the following days (taking surgery into account), with a maximum ultra-sensitive troponin I concentration of 4000<span class="elsevierStyleHsp" style=""></span>pg/ml (normal 2–15.6<span class="elsevierStyleHsp" style=""></span>pg/ml). In contrast, the electrocardiographic tracing showed significant changes with respect to the previous recordings, with a long QTc (680<span class="elsevierStyleHsp" style=""></span>ms) and the appearance of inverted T-waves on precordial leads during several days (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). The electrolyte profile and rest of the laboratory test parameters were normal.</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Venous-arterial ECMO was maintained for four days, allowing the withdrawal of vasoactive drug support, and followed by a favorable clinical course. The echocardiographic studies revealed gradual improvement of ventricular function. The patient was extubated a few days later and moved to the hospital ward, where she remained until discharge in good functional condition. The last echocardiographic exploration showed slight anterior septal and inferior hypokinesia, with globally preserved systolic function.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this case the diagnosis of Takotsubo syndrome was established from the echocardiographic findings, the absence of previous coronary lesions, scant alteration of the cardiac enzyme levels despite the ventricular dysfunction and surgery, and the precordial electrocardiographic tracings (inverted T-waves and long QT syndrome, with normal electrolyte levels). There has been an increase in the number of diagnoses of this syndrome in recent years,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">2</span></a> also in cardiovascular surgery patients,<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">3–5</span></a> though Takotsubo syndrome has not been previously described in the postoperative period of atrial myxoma resection.</p><p id="par0035" class="elsevierStylePara elsevierViewall">The etiology and physiopathology of Takotsubo syndrome have not been fully established, though a number of mechanisms have been proposed, such as coronary vasospasm, coronary microvascular functional anomalies, and particularly catecholamine-mediated cardiotoxicity. Probably because of this, the main risk factor is considered to be stress (both physical and mental), which is present in different diagnostic tests and surgical procedures–especially those of an emergent or urgent nature.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">6</span></a> Cardiac surgery and extracorporeal circulation generate important stress, and may intrinsically account for the appearance of Takotsubo syndrome, particularly if the epidemiological profile of the patient and the echocardiographic and electrocardiographic features are consistent with the diagnostic criteria, as in our case. The differential diagnosis includes coronary embolism or poor myocardial protection. The typical echocardiographic findings, with scant enzyme alterations, brief surgery without incidents, and previous hemodynamic stability with a normal first electrocardiographic tracing allow us to reasonably discard both of the aforementioned disorders. In recent years, evidence has been gained suggesting that magnetic resonance imaging may be useful in establishing a differential diagnosis with other disorders such as myocarditis or coronary embolism,<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">7</span></a> though this technique could not be used in our case.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Of note is the appearance of a long QT interval on the electrocardiographic tracing. The association between Takotsubo myocardiopathy and transient prolongation of the QT interval has been documented,<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">8,9</span></a> being more frequent in patients with some form of heart disease, previous long QT syndrome, or genetic alterations. In Takotsubo syndrome, electrocardiographic normalization occurs approximately two months after the episode. Although malignant ventricular arrhythmias, sudden death or cardiac block are infrequent, there have been reports of such situations. Increased QT prolongation (QTc<span class="elsevierStyleHsp" style=""></span>><span class="elsevierStyleHsp" style=""></span>500<span class="elsevierStyleHsp" style=""></span>ms) has been identified as a risk factor for complications of this kind; close monitoring of the cardiac rhythm is thus required, with the prevention or treatment of arrhythmias and the implantation of a pacemaker if necessary.</p><p id="par0045" class="elsevierStylePara elsevierViewall">In conclusion, Takotsubo syndrome is an infrequent cause of cardiogenic shock in the postoperative period of heart surgery, though it must be considered in patients with apparently uncomplicated surgery, normal coronary vessels and compatible echocardiographic findings, since the prognosis is generally good when adequate supportive treatment is provided.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial support</span><p id="par0050" class="elsevierStylePara elsevierViewall">This study has received no financial support.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial support" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: García-Delgado M, García-Huertas D, Navarrete-Sánchez I, Olivencia-Peña L, Garrido JM. Soporte con oxigenación de membrana extracorpórea en un síndrome de Takotsubo y QT largo tras cirugía cardiaca. Med Intensiva. 2017;41:441–443.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 742 "Ancho" => 990 "Tamanyo" => 90267 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Apical projection view of the four chambers, showing the atrial myxoma penetrating into the left ventricle through the mitral valve.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 913 "Ancho" => 2000 "Tamanyo" => 291630 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">(A) Twelve-lead electrocardiographic tracing corresponding to day two after onset of the condition, with a QTc interval of 680<span class="elsevierStyleHsp" style=""></span>ms. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 2 | 3 | 5 |
| 2024 October | 48 | 58 | 106 |
| 2024 September | 50 | 44 | 94 |
| 2024 August | 59 | 42 | 101 |
| 2024 July | 57 | 37 | 94 |
| 2024 June | 68 | 47 | 115 |
| 2024 May | 47 | 28 | 75 |
| 2024 April | 58 | 41 | 99 |
| 2024 March | 61 | 38 | 99 |
| 2024 February | 39 | 39 | 78 |
| 2024 January | 35 | 40 | 75 |
| 2023 December | 43 | 36 | 79 |
| 2023 November | 36 | 36 | 72 |
| 2023 October | 33 | 26 | 59 |
| 2023 September | 34 | 35 | 69 |
| 2023 August | 23 | 15 | 38 |
| 2023 July | 29 | 41 | 70 |
| 2023 June | 30 | 21 | 51 |
| 2023 May | 37 | 28 | 65 |
| 2023 April | 35 | 29 | 64 |
| 2023 March | 62 | 36 | 98 |
| 2023 February | 86 | 25 | 111 |
| 2023 January | 90 | 18 | 108 |
| 2022 December | 87 | 42 | 129 |
| 2022 November | 77 | 40 | 117 |
| 2022 October | 51 | 23 | 74 |
| 2022 September | 52 | 39 | 91 |
| 2022 August | 58 | 58 | 116 |
| 2022 July | 46 | 53 | 99 |
| 2022 June | 52 | 21 | 73 |
| 2022 May | 54 | 42 | 96 |
| 2022 April | 46 | 48 | 94 |
| 2022 March | 69 | 59 | 128 |
| 2022 February | 37 | 46 | 83 |
| 2022 January | 44 | 31 | 75 |
| 2021 December | 32 | 42 | 74 |
| 2021 November | 42 | 39 | 81 |
| 2021 October | 58 | 73 | 131 |
| 2021 September | 44 | 40 | 84 |
| 2021 August | 32 | 51 | 83 |
| 2021 July | 23 | 41 | 64 |
| 2021 June | 35 | 38 | 73 |
| 2021 May | 45 | 52 | 97 |
| 2021 April | 67 | 94 | 161 |
| 2021 March | 61 | 43 | 104 |
| 2021 February | 53 | 31 | 84 |
| 2021 January | 48 | 29 | 77 |
| 2020 December | 45 | 27 | 72 |
| 2020 November | 25 | 20 | 45 |
| 2020 October | 41 | 29 | 70 |
| 2020 September | 39 | 22 | 61 |
| 2020 August | 30 | 22 | 52 |
| 2020 July | 29 | 24 | 53 |
| 2020 June | 37 | 21 | 58 |
| 2020 May | 35 | 9 | 44 |
| 2020 April | 30 | 9 | 39 |
| 2020 March | 25 | 13 | 38 |
| 2020 February | 79 | 31 | 110 |
| 2020 January | 38 | 26 | 64 |
| 2019 December | 49 | 20 | 69 |
| 2019 November | 42 | 38 | 80 |
| 2019 October | 21 | 19 | 40 |
| 2019 September | 31 | 25 | 56 |
| 2019 August | 28 | 33 | 61 |
| 2019 July | 25 | 22 | 47 |
| 2019 June | 20 | 18 | 38 |
| 2019 May | 43 | 36 | 79 |
| 2019 April | 15 | 21 | 36 |
| 2019 March | 14 | 30 | 44 |
| 2019 February | 23 | 31 | 54 |
| 2019 January | 27 | 37 | 64 |
| 2018 December | 62 | 18 | 80 |
| 2018 November | 102 | 61 | 163 |
| 2018 October | 93 | 24 | 117 |
| 2018 September | 53 | 18 | 71 |
| 2018 August | 24 | 14 | 38 |
| 2018 July | 36 | 21 | 57 |
| 2018 June | 42 | 15 | 57 |
| 2018 May | 50 | 9 | 59 |
| 2018 April | 43 | 19 | 62 |
| 2018 March | 103 | 29 | 132 |
| 2018 February | 30 | 14 | 44 |
| 2017 October | 0 | 1 | 1 |
| 2017 August | 0 | 1 | 1 |
| 2017 July | 1 | 0 | 1 |
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