Nahuel L. Melón-Ramírez, Servicio de Cardiología, Instituto de Medicina Cardiovascular, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Daniela S. Grigorian, Servicio de Cardiología, Instituto de Medicina Cardiovascular, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Rocío Blanco, Servicio de Cardiología, Instituto de Medicina Cardiovascular, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Aníbal Arias, Servicio de Cardiología, Instituto de Medicina Cardiovascular, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
Rodolfo Pizarro, Servicio de Cardiología, Instituto de Medicina Cardiovascular, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
We present the case of a 66-year-old woman with a history of hypertension and no prior cardiac disease who presented with oppressive chest pain following physical exertion. The electrocardiogram showed T-wave inversion in the inferior and anterolateral leads, along with elevation of high-sensitivity troponin T. Given the suspicion of acute coronary syndrome, coronary angiography was performed and revealed no significant coronary artery disease. Transthoracic echocardiography demonstrated apical hypokinesia with a left ventricular ejection fraction of 50%, basal hypercontractility with a dynamic left ventricular outflow tract (LVOT) gradient, and moderate mitral regurgitation secondary to systolic anterior motion of the anterior mitral leaflet, establishing the diagnosis of Takotsubo cardiomyopathy. During hospitalization, the patient developed hypotension and signs of low cardiac output after diuretic administration, interpreted as worsening of the dynamic intraventricular gradient. Diuretics were discontinued, and hemodynamic resuscitation with crystalloids and norepinephrine was initiated, resulting in rapid clinical improvement. On day three, follow-up echocardiography demonstrated normalization of left ventricular systolic function and complete resolution of the dynamic gradient and mitral regurgitation. This case highlights the importance of recognizing dynamic LVOT obstruction in complicated Takotsubo cardiomyopathy, as conventional heart failure therapies may be harmful and should be replaced by an individualized, echocardiography-guided hemodynamic management strategy.
Keywords: Takotsubo syndrome. Stress cardiomyopathy. Dynamic obstruction of the left ventricular outflow tract. Mitral regurgitation. Systolic anterior movement of the anterior leaflet. Acute heart failure.
