A Rare Case Of Peripartum Takotsubo Cardiomyopathy

• Published in: Journal of cardiac failure Vol. 29; no. 4; p. 706
• Main Authors: Faiz, Fardeen, Fernandes, Robin, Banasiewicz, Benjamin, Saunders, Courtney
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.04.2023
• ISSN: 1071-9164; 1532-8414
• DOI: 10.1016/j.cardfail.2022.10.397

Takotsubo cardiomyopathy is characterized by left ventricular dysfunction with apical ballooning in the absence of significant coronary artery disease. Though rare in pregnancy, this transient cardiac dysfunction may affect women in antepartum, intrapartum, or postpartum period, making it difficult to discern the inciting event or differentiate from spontaneous coronary artery dissection or peripartum cardiomyopathy. Most patients respond well to medical management with spontaneous resolution of cardiac dysfunction within weeks of diagnosis. A 38-year-old female G3P0202 at 36 weeks of gestation with a history of preeclampsia, hypertension, hyperlipidemia, and recent COVID-19 infection presented with severe substernal chest pain. She was hypertensive on arrival with a blood pressure of 220/120 mm Hg. Electrocardiogram showed T-wave inversion in the anterior leads and troponin I level was 2.6 ng/ml. She was treated with aspirin 324 mg, IV hydralazine 20 mg, IV magnesium sulfate infusion for seizure prophylaxis and fetal neuroprotection. A transthoracic echocardiogram revealed left ventricular ejection fraction of 35-40% with apical ballooning. Urgent left heart catheterization did not show signs of epicardial coronary artery disease, prompting the diagnosis of Takotsubo cardiomyopathy. Hospital course included interdisciplinary team-based medical therapy until cesarean section 24 hours after arrival. Following delivery, she was started on guideline directed medical therapy for heart failure and discharged home. At her one month follow-up, she was still experiencing symptoms of heart failure and classified as New York Heart Association Class II. Stress-induced cardiomyopathy rarely occurs in gravid females with chest pain; however, it should be considered after ruling out acute myocardial infarction. Distinguishing Takotsubo cardiomyopathy from peripartum cardiomyopathy is important as peripartum cardiomyopathy is considered a contraindication for future pregnancies. Clinical suspicion for Takotsubo cardiomyopathy should be increased in patients with a history of superimposed preeclampsia. Whether COVID-19 infection-associated inflammatory state predisposes high risk pregnant patients to Takotsubo cardiomyopathy is unknown, but this is a possible inciting factor that should be assessed in patient work up. Management should involve an interdisciplinary team approach to ensure the safety of mother and child.