Reverse stress cardiomyopathy post-liver transplant needing mechanical circulatory support.

A 39-year-old female patient with hepatitis B-related decompensated chronic liver disease underwent living donor liver transplantation. Preoperatively, she had a normal electrocardiogram (ECG) and echocardiography, and also a negative dobutamine stress echocardiography test. Intraoperative course went uneventful. Two hours postoperatively, she developed hypotension. Initially, hypotension was treated with fluids and blood products after confirming normal echocardiography, but with time, patient's haemodynamics worsened. Repeat echocardiography showed postero-inferior regional wall motion abnormality. Troponin I was significantly elevated, but ECG was normal. Suspecting myocardial infarction coronary angiography was done which was normal. Based on Mayo's criteria, patient was diagnosed with reverse Takotsubo cardiomyopathy since postero-inferior wall was involved. Inotropic support failed to maintain haemodynamics and intra-aortic balloon pump (IABP) was placed. Inotropes were gradually tapered and IABP was removed at day 4. Twenty days later, repeat echocardiography was normal and patient was subsequently discharged.

INTRODUCTION

Takotsubo cardiomyopathy is a reversible form of non-ischaemic cardiomyopathy, which is characterised by transient left ventricle apical and midsystolic dysfunction with basal hyperkinesis and the reverse type[12] with hyperdynamic apex and akinesis of the base of the left ventricle. The affected heart, when viewed by echocardiography or catheterisation, mimics a shape described as a round-bottomed narrow-necked Japanese fishing pot used to trap octopus, which in Japanese is called “takotsubo”.[34] The pathophysiologic mechanism is unclear. Though it has a benign course, it can lead to significant mortality and morbidity.

CASE REPORT

A 39-year-old female patient with hepatitis B virus-related chronic liver disease, portal hypertension, splenomegaly, ascites and pancytopenia was planned for living donor liver transplantation after graft matching was done. Her Child–Turcotte Pugh and model for end-stage liver disease (MELD) scores were 11 and 18, respectively. Preoperatively, she had a normal electrocardiogram (ECG), left ventricular ejection fraction (LVEF) 55–60%, normal pulmonary artery systolic pressure (PASP) and negative dobutamine stress test. Consent for anaesthesia was obtained and modified rapid sequence induction was performed with endotracheal intubation with standard institutional protocol. Induction was uneventful.

Intraoperative monitoring included, electrocardiogram (ECG), pulse oximetry (SpO2), non-invasive blood pressure (NIBP) and end-tidal carbon dioxide, invasive blood pressure, cardiac output monitoring using Flowtrac EV 1000, central venous pressure and hourly urine output. Haemodynamics were managed with fluids, albumin, calcium, vasopressors and thromboelastography-guided blood products' transfusion. She received 20 packed red blood cells (PRBC), 18 fresh frozen plasma (FFP), 2 single donor platelets and 10 cryoprecipitates. Reperfusion was uneventful.

The patient was shifted intubated, sedated and paralysed to ICU on noradrenaline (0.4 mcg/kg/min) and vasopressin (0.02 U/min) infusions with haemodynamic indices of heart rate (HR) 80/min, mean arterial pressure (MAP) 82 mmHg, cardiac index (CI) 3.5 l/m2, systemic vascular resistance (SVR) 998 dynes.sec/cm5, stroke volume (SV) 74 ml and stroke volume variation (SVV) 5%.

She developed hypotension after 2 h with haemodynamic indices of HR 110/min, MAP 50 mmHg, CI 1.9 l/m2, SVR 1438 dynes.sec/cm5, SV 28 ml and SVV 20% which was managed with fluid boluses, increasing vasopressors and 2 PRBCs and 3 FFP transfusions (haemoglobin: 8 g/dl, international normalised ratio: 3). There was no increase in drain output, which was sero-sanguineous. Ultrasound abdomen including Doppler showed normal portal vein and hepatic artery flow with no evidence of collection and transthoracic echocardiography (TTE) showed no regional wall motion abnormality (RWMA). Thereafter, patient developed pulmonary oedema with arterial blood gas showing PaO2 of 62 mmHg with FiO2 of 0.7 along with raise in lactate of 4 mmol/L and basal crepitations on auscultation for which she received injection furosemide. Injection morphine was given and fluids were restricted. Haemodynamic indices were CI 2 l/m2, SVR 1378 dynes.sec/cm5, SV 35 ml and SVV 5%.

After 6 h, despite high vasopressor support, hypotension persisted and was accompanied by drop in urine output; hence, a repeat TTE was done. It revealed global left ventricular hypokinesia with relative akinesia of postero-inferior wall with LVEF of 25–30% and PASP of 50 mmHg with dilated left ventricle. Injection adrenaline (0.05 mcg/kg/min) was started for inotropic effect. Trop-I was sent and found to be positive, but ECG was normal. Coronary angiography showed patent coronary arteries. Meanwhile, NT-pro BNP was sent which showed 26,603 pg/ml. Intra-aortic balloon pump (IABP) was considered and inserted through right femoral artery with counter pulsations of 1:2 ratio. Subsequently, vasopressors were tapered down and urine output improved.

On the fourth postoperative day, TTE showed LVEF of 35% and PASP of 38 mmHg and IABP was removed. Patient was on minimal inotropic support which was tapered gradually. Patient was tracheostomised on seventh postoperative day. On the 13th postoperative day, TTE had a LVEF of 55%, no RWMA and PASP of 34 mmHg. Patient was gradually weaned off the ventilator and tracheostomy closed on the 18th postoperative day. Three days later, patient was shifted to the ward and subsequently discharged.

DISCUSSION

We postulated that our patient may have suffered from stress cardiomyopathy based on Mayo's criteria.[5] At our centre with an experience of over 150 liver transplants, the current case is the first case of acute stress-induced cardiomyopathy that we have encountered.

In our case, initially hypotension was treated with fluids and blood products considering that echocardiography was normal, but patient went into pulmonary oedema and with time patients haemodynamics worsened. When echocardiography was repeated, it showed postero-inferior RWMA [Figures 1 and 2], and Trop-I and ECG were done. Troponin I was significantly elevated, but surprisingly ECG was normal.

Figure 1

Transthoracic echocardiography-parasternal long axis view showing inferior wall hypokinesia

Figure 2

Transthoracic echocardiography-parasternal short axis view showing posterior wall hypokinesia

On the grounds of suspicion that patient had myocardial infarction, coronary angiography was done on her, which turned out to be normal. Based on Mayo's criteria, patient was diagnosed with reverse takotsubo cardiomyopathy syndrome since postero-inferior wall was involved and treated accordingly. Despite high inotropic support, patient's haemodynamics were not maintained well and hence decided to put IABP. IABP can be used in an acute setting of cardiogenic shock for haemodynamic support. Most of the reported cases responded well to diuretics and inotropic support, but in our case, patient needed mechanical circulatory support. Elapavaluru et al.[6] demonstrated the use of IABP in perioperative stress cardiomyopathy in simultaneous liver and kidney transplantation. Tiwari[3] in a case of refractory heart failure demonstrated the use of IABP successfully. Vachiat et al.[7] in their case had used left ventricular assist device as rescue measure successfully. For reasons unknown, this syndrome predominantly occurs in elderly and post-menopausal women. [Videos 1 and 2]

CONCLUSION

Takotsubo syndrome is a less known cause of hypotension post-liver transplant. Use of IABP can be reserved in situations where need for vasopressor support is increasing with poor left ventricular function. It is imperative to diagnose quickly as early recognition and treatment is the key to improve outcomes.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.