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CASE REPORT Table of Contents   
Year : 2008  |  Volume : 11  |  Issue : 1  |  Page : 38-41
Tako-Tsubo syndrome in an anaesthetised patient undergoing arthroscopic knee surgery


Department of Anaesthesiology, McGill University Health Center, McGill University, Montréal, Québec, Canada

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   Abstract 

We present a case of stress-induced myocardial stunning, also known as tako-Tsubo syndrome, in an anaesthetised patient undergoing arthroscopic replacement of the cruciate ligament. The patient's (44 y male, ASA class II) had a history of hypertension with no other known disease. He underwent a femoral nerve block with 20 ml of 0.5% ropivacaine before receiving a balanced general anaesthesia (propofol induction, sevoflurane maintenance, 10 µg/kg sufentanil). Ten min after the beginning of surgery during endoscopic intra-articular manipulation, the patient suffered from bradycardia and hypotension; following the administration of ephedrine and atropine, he developed tachycardia, hypertension and ST segment depression. Subsequently, his systemic blood pressure dropped necessitating inotropic drug support and - later - intraaortic balloon counterpulsation; a TEE revealed no evidence of hypovolemia, anterior and antero-septal hypokinesia with an ejection fraction of 25%. Surgery was finished whilst stabilising the patient haemodynamically. Postoperative cardiac enzymes showed little elevation, an emergency coronary angiogram apical akinesia with typical ballooning and basal hyperkinesias, compatible with Tako-tsubo syndrome. The patient's postoperative course was uneventful. We theorize that stress caused by sudden surgical pain stimulus (introduction of the endoscope into the articulation), superficial anaesthesia and insufficient analgesia created a stressful event which probably might have caused a catecholamine surge as basis of Tako-tsubo syndrome.

Keywords: General anaesthesia, Tako-Tsubo syndrome, broken heart syndrome, myocardial stunning

How to cite this article:
Artukoglu F, Owen A, Hemmerling TM. Tako-Tsubo syndrome in an anaesthetised patient undergoing arthroscopic knee surgery. Ann Card Anaesth 2008;11:38-41

How to cite this URL:
Artukoglu F, Owen A, Hemmerling TM. Tako-Tsubo syndrome in an anaesthetised patient undergoing arthroscopic knee surgery. Ann Card Anaesth [serial online] 2008 [cited 2020 Sep 20];11:38-41. Available from: http://www.annals.in/text.asp?2008/11/1/38/38448


Tako-Tsubo syndrome, also known as stress-induced myocardial stunning, is defined as a combination of acute chest pain, ST segment changes and transient left ventricular (LV) apical wall motion abnormalities that mimics acute myocardial infarction (AMI). It presents surprisingly normal coronary angiography findings. [1] The name is derived from the octopus trap, used for catching octopuses in Japan, due to the shape of the LV in the left ventriculogram caused by apical akinesia and basal hyperkinesis. Although most cases have been initially described in Japan, [2] there are reports from other parts of the world also. [1] As a result of extremely common presenting symptoms such as chest pain and dyspnea, the diagnosis might be particularly difficult in an anaesthetised patient. Here, we report the case of tako-tsubo syndrome in an anaesthetised patient, who presented first with an intraoperative pulmonary oedema, followed by LV failure.


   Case Report Top


A 44-year-old (American Society of Anesthesiologists status II, 90 kg) male patient presented for an arthroscopic left anterior cruciate ligament (ACL) repair. He had a past surgical history of diaphragmatic hernia repair, with an uneventful general anaesthesia (GA). He also had a history of hypertension, for which he occasionally used anti-hypertensive medications; he could not remember the name of the drug, and his compliance with the usage of the medication was questionable. He had no known drug allergies and the results of the preoperative laboratory tests were within the normal ranges. The preoperative blood pressure was 130/75 mmHg and heart rate (HR), 70 beats/min. Prior to the operation, following a premedication with 2 mg intravenous (IV) midazolam, he received a left femoral nerve block with 20 ml of 0.5% ropivacaine. The lowest stimulation threshold for the block was 0.45 mA, with negative blood aspiration. Intraoperative monitoring consisted of a 3-lead electrocardiogram (ECG), non-invasive blood pressure measurement and pulse oximetry. GA was induced with 200 mg propofol and 10 µg sufentanil (IV). A number 4 laryngeal mask airway was successfully inserted for providing assisted spontaneous ventilation. Anaesthesia was maintained with sevoflurane, adjusted to a minimum alveolar concentration of 1.0 and breathing air in 50% oxygen. The end-tidal carbon dioxide was maintained in the range of 30-35 mmHg. Ten minutes following the commencement of surgery, during endoscopic intra-articular manipulation, the patient developed bradycardia (HR of 30 beats/min) and the systolic blood pressure (SBP) decreased to 80 mmHg. There was no response to two consecutive administrations of 5 mg ephedrine (IV) at 5 min intervals (administration of ephedrine in presence of hypotension and bradycardia is recommended in the departmental policy); however, following administration of 0.6 mg atropine (IV), the HR increased to 150 beats/min and the SBP, to 250 mmHg. An ST segment depression of 0.4 mm was observed on the ECG monitor. The patient's response to 100 mg propofol, 100 mg esmolol and two consecutive sublingual administrations of nitroglycerine (0.4 mg) was minimal, decreasing the HR to 110 beats/min and SBP to 150 mmHg within 2-3 min. Subsequently, the patient's oxygen saturation (SpO 2 ) decreased and ventilation through the laryngeal mask airway proved difficult. Rocuronium (50 mg, IV) was administered and the trachea intubated with an 8-mm endotracheal tube (ETT). Suction of the ETT revealed a pink frothy secretion. The SBP of the patient began decreasing and it was maintained at 80 mmHg (at this point, the HR remained between 110 and 120 beats/min) by intravenous phenylephrine boluses. Transoesophageal echocardiography revealed a normal volume status (no evidence of hypovolemia), LV ejection fraction (EF) of 25%, with significant segmental wall motion abnormality (particularly on the anterior and anteroseptal segments), with mild to moderate mitral regurgitation. A right internal jugular vein catheter was inserted and 0.5 µg/kg/min phenylephrine started. In the subsequent 5 min, following no adequate response to phenylephrine infusion, an infusion of 10 µg/min norepinephrine (NE) was commenced to maintain haemodynamic support. An intraaortic balloon pump (IABP) was placed while the ACL was repaired. At the end of surgery, the patient remained intubated and ventilated, with an ongoing IABP therapy. An emergency coronary angiography showed no significant, demonstrable obstructive coronary disease. However, the left ventriculogram remained abnormal, with apical akinesia and basal hyperkinesia, an EF of 35% and showing a LV apical ballooning [Figure - 1]. The patient was transferred to the intensive care unit and electively ventilated. He received intravenous infusions of propofol (50 µg/kg/min) and NE (12 µg/min). The troponin I level was 0.25 µg/L (normal, <0.04 µg/L). On postoperative day 1 (POD #1), a test transoesophageal echocardiography showed normal LV systolic function with no segmental wall motion abnormality. On the same day, the troponin I level decreased to 0.15 µg/L. Following a stable haemodynamic course, NE infusion was discontinued. IABP was discontinued followed by extubation of the trachea. On POD #2, the patient was discharged to the ward and on POD #5, to home.


   Discussion Top


Tako-Tsubo cardiomyopathy, also known as broken heart syndrome, ampulla cardiomyopathy or transient LV apical ballooning, is a potentially life-threatening but rapidly reversible condition that mimics AMI. The principal features of this syndrome are: (1) Acute psychological/physical stress before the onset of chest pain or dyspnea; (2) Ischemic changes on the ECG; (3) Normal epicardial coronary arteries; (4) Apical ballooning with basal hyperkinesis on the left ventriculogram; (5) disproportionately low release of cardiac enzymes with respect to degree of LV dysfunction and (6) Rapid resolution of LV dysfunction. [3]

Neurogenic myocardial stunning is a well-known disorder occurring in patients with intracerebral haemorrhage; it is caused by an increased central sympathetic activity, which results in a hyperdynamic cardiovascular state. [4] It may be observed pre-, intra- or postoperatively. The rapidly reversible course of neurogenic myocardial stunning is very similar to that observed in the tako-tsubo syndrome. The Along with basal LV segment stunning, echocardiographic observation of a spared apex can aid in differentiating tako-tsubo syndrome from neurogenic myocardial stunning. [5] Since the last 4 years, several reports on tako-tsubo syndrome have been published; however, only one report describes an anaesthetised patient. [6] Significant haemodynamic compromise (as observed in the present case) was not observed in the abovementioned report; the only significant sign or symptom demonstrated was sinus tachycardia without any other ECG changes. It was diagnosed by postoperative echocardiography and resolved on POD #3.

Although the presence of a psychological or physical stress is accepted as one of the main features of the tako-tsubo syndrome, 22.8% of the cases have been reported to occur without any triggering effect. [7] Catecholamine surge is one of the projected mechanisms that causes cardiac stunning in the tako-tsubo syndrome. [8] Inadequate GA and partial femoral nerve block causing insufficient analgesia may be the underlying causes in this case. Interestingly, Nicholson et al. , [9] showed that a "three-in-one" nerve block (femoral nerve, lateral cutaneous nerve of thigh and obturator nerve) was not sufficient for preventing the neuroendocrine stress response in major orthopedic surgery cases, resulting in increased plasma levels of epinephrine and norepinephrine.

Several aspects of management in this case need commenting. Firstly, ephedrine was selected as the first line of treatment instead of atropine. This is because of a departmental policy to select ephedrine instead of atropine in the event of combined occurrence of bradycardia and hypotension. Since the patient was suffering from untreated hypotension, an SAP of 80 mmHg was considered severe hypotension and ephedrine thus selected. However, in the light of this case with two unsuccessful repetitive doses of ephedrine with bradycardia and hypotension, a change in the departmental policy toward atropine as a first choice in case of severe bradycardia, followed by ephedrine if hypotension continues, has been suggested. Secondly, the first hypertensive response was treated with esmolol and nitroglycerine. However, the SAP and HR only decreased to 150 mmHg and 110 beats/min, respectively. The first presumptive diagnosis was AMI and under this presumption, the use of a b-blocking agent combined with nitroglycerine appears appropriate. Thirdly, the treatment of the following moderate to severe hypotension consisted of norepinephrine and insertion of an IABP. Norepinephrine was preferred over epinephrine because the concomitant tachycardia with norepinephrine was thought to be lower than that with epinephrine. IABP was inserted to further stabilise the haemodynamics with the idea to proceed from the confirmation of the diagnosis of myocardial infarction to immediate cardiac surgery.

Tako-tsubo syndrome is a rare disorder. In a recent study, [1] the annual incidence of this syndrome in a Western population was calculated to be 0.00006%. Interestingly, in the Japanese population, the prevalence of this syndrome has been reported to be considerably higher, i.e., 1%. [2] There might be a genetic component that has not been discovered yet. Discovery can usually be made with the aid of the abovementioned clinical signs and the typical angiographic imaging. In addition, a specific aberration should be investigated - the so-called midventricular tako-tsubo syndrome [10] - showing a typical "hawk's beak" attachment at the apex; this attachment was not found in our case.

In conclusion, we present the case of tako-tsubo syndrome in a patient undergoing orthopedic surgery conducted under GA. Sufficiently deep anaesthesia and analgesia during arthroscopic knee surgeries may avoid surges in catecholamine levels in this potentially life-threatening but rapidly reversible syndrome.

 
   References Top

1.Klinceva M, Widimský P, Pesl L, Stαsek J, Tousek F, Vambera M, et al. Prevalence of stress-induced myocardial stunning (Tako-Tsubo cardiomyopathy) among patients undergoing emergency coronary angiography for suspected acute myocardial infarction. Int J Cardiol 2007;120:411-3.  Back to cited text no. 1    
2.Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: A review of 5 cases. J Cardiol 1991;21:203-14.  Back to cited text no. 2  [PUBMED]  
3.Iqbal MB, Moon JC, Guttmann OP, Shanahan P, Goadsby PJ, Holdright DR. Stress, emotion and the heart: tako-tsubo cardiomyopathy. Postgrad Med J 2006;82:e29.  Back to cited text no. 3  [PUBMED]  [FULLTEXT]
4.Mayer SA, Lin J, Homma S, Solomon RA, Lennihan L, Sherman D, et al. Myocardial injury and left ventricular performance after subarachnoid hemorrhage. Stroke 1999;30:780-6.  Back to cited text no. 4  [PUBMED]  [FULLTEXT]
5.Deininger MH, Radicke D, Buttler J, Scheufler KM, Freiman T, Zentner JF. Tako-tsubo cardiomyopathy: Reversible heart failure with favorable outcome in patients with intracerebral hemorrhage: Case report. J Neurosurg 2006;105:465-7.  Back to cited text no. 5    
6.Takigawa T, Tokioka H, Chikai T, Fukushima T, Ishizu T, Kosogabe Y. A case of undiagnosed "takotsubo" cardiomyopathy during anaesthesia. Masui 2003;52:1104-6.  Back to cited text no. 6  [PUBMED]  
7.Donohue D, Movahed MR. Clinical characteristics, demographics and prognosis of transient left ventricular apical ballooning syndrome. Heart Fail Rev 2005;10:311-6.  Back to cited text no. 7  [PUBMED]  [FULLTEXT]
8.Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539-48.  Back to cited text no. 8    
9.Nicholson G, Bryant AE, Macdonald IA, Hall GM. Osteocalcin and the hormonal, inflammatory and metabolic response to major orthopaedic surgery. Anaesthesia 2002;57:319-25.  Back to cited text no. 9  [PUBMED]  
10.Roncalli J, Carrie D, Fauvel JM, Losordo DW. A "hawk's beak" to identify the new transient midventricular Tako-Tsubo syndrome. Int J Cardiol 2007;[Epub ahead of print].  Back to cited text no. 10    

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Correspondence Address:
Thomas M Hemmerling
Department of Anesthesiology, McGill University, Montreal General Hospital, 1650 Cedar Avenue, Montreal, H3G 1A4
Canada
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0971-9784.38448

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