Levosimendan: the inotrope of choice in cardiogenic shock secondary to takotsubo cardiomyopathy?

Takotsubo cardiomyopathy (TC) has become an increasingly recognised entity in Western literature since its initial reporting in Japan. The pathogenesis underlying the myocardial stunning and systolic dysfunction is thought to be induced by elevated systemic levels of catecholamines and neuropeptides. Whilst the majority of patients are haemodynamically stable, a small proportion can develop cardiogenic shock. This creates a therapeutic dilemma because inotropic support using exogenous catecholamines (adrenaline, dobutamine, dopamine) may be counter-productive. Two cases where the calcium sensitiser levosimendan (a non-catecholamine inotrope) was used successfully in TC-related cardiogenic shock are presented. The management of circulatory compromise in TC is then discussed.