REVISTA
BRASILEIRA
DE
ANESTESIOLOGIA
PublicaçãoOficialdaSociedadeBrasileiradeAnestesiologiawww.sba.com.br
CLINICAL
INFORMATION
Perioperative
approach
of
patient
with
takotsubo
syndrome
Joana
Barros
∗,
Diana
Gomes,
Susana
Caramelo,
Marta
Pereira
CentroHospitalardeTrás-os-MonteseAltoDouro,EPE,VilaReal,Portugal
Received21September2014;accepted4November2014
Availableonline17September2016
KEYWORDS
Takotsubosyndrome; Anesthesia;
Cardiomyopathy; Stress
Abstract
Introduction:Takotsubocardiomyopathy(TCM)isastress-inducedcardiomyopathy.Itis char-acterizedbyanacuteonsetofsymptomsandelectrocardiographicabnormalitiesmimickingan acutecoronarysyndromeintheabsenceofobstructivecoronaryarterydisease.Any anesthetic-surgicaleventcorrespondstoastressfulsituation,sotheanestheticmanagementofpatients withTCMrequiresspecialcarethroughouttheperioperativeperiod.Wedescribetheanesthetic managementofapatientwithaconfirmeddiagnosisofTCMundergoingsegmentalcolectomy.
Casereport: Femalepatient,55yearsold,ASAIII,withhistoryoftakotsubosyndrome diag-nosed2yearsago,scheduledforsegmentalcolectomy.Thepatient,withoutotherchangesin preoperative evaluation,underwentgeneralanesthesiaassociated withlumbarepiduraland remained hemodynamically stableduringthe 2h ofsurgery.After abrief stay in the Post-AnesthesiaCareUnit,shewastransferredtotheIntermediateCareUnit(IMCU),withepidural analgesiaforpostoperativeperiod.
Conclusion: TCMisararediseasewhichtruepathophysiologyremainsunclear,aswellasthe mostappropriateanesthetic-surgicalstrategy.Inthiscase,throughapreventiveapproach,with closemonitoringandthelowestpossiblestimulus,alltheperioperativeperiodwasuneventful. Becauseitisararedisease,thisreportcouldhelptoraiseawarenessaboutTCM.
©2015SociedadeBrasileiradeAnestesiologia.Publishedby ElsevierEditoraLtda.Thisisan openaccessarticleundertheCCBY-NC-NDlicense( http://creativecommons.org/licenses/by-nc-nd/4.0/).
∗Correspondingauthor.
E-mails:joana.20.barros@gmail.com,pipasurfista@gmail.com(J.Barros).
http://dx.doi.org/10.1016/j.bjane.2014.11.003
PALAVRAS-CHAVE
Síndromede takotsubo; Anestesia; Miocardiopatia; Estresse
Abordagemperioperatóriadedoentecomsíndromedetakotsubo
Resumo
Introduc¸ão:A miocardiopatia takotsubo (MT)é uma miocardiopatia induzida peloestresse. Caracteriza-seporuminícioagudodesintomasealterac¸ões eletrocardiográficasque mime-tizam uma síndrome coronária aguda naausência de doenc¸a arterial coronária obstrutiva. Qualquer evento anestésico-cirúrgico corresponde a uma situac¸ão de estresse, pelo que a abordagemanestésicadosdoentescomMTexigeumcuidadoespecialemtodooperíodo peri-operatório.Descrevemosaabordagemanestésicadeumadoentecomdiagnósticoconfirmado deMTsubmetidaacolectomiasegmentar.
Casoclínico:Pacientedosexofeminino,55anos,ASAIII,comantecedentesdesíndromede takotsubodiagnosticadahaviadoisanos,encaminhadaparacolectomiasegmentar.Apaciente, semoutrasalterac¸õesnaavaliac¸ãopré-operatória,foisubmetidaaanestesiageralassociada aepidurallombaremanteve-sehemodinamicamenteestávelduranteasduashorasdo pro-cedimentocirúrgico. Apósumabreve permanêncianaUnidadede CuidadosPós-Anestésicos foitransferidaparaaUnidadedeCuidadosIntermédios(UCIM)comanalgesiaperiduralparao pós-operatório.
Conclusão:A MTéumadoenc¸arara,cujaverdadeirafisiopatologiacontinuaporesclarecer, assimcomoaestratégiaanestésico-cirúrgicamaisapropriada.Nessecaso,porcausadeuma abordagempreventiva,commonitorac¸ãorigorosaeomenorestímulopossível,todoo periop-eratóriodecorreusemintercorrências.Sendoumadoenc¸arara,oseurelatopoderácontribuir paraoavanc¸odoconhecimentosobreaMT.
©2015SociedadeBrasileiradeAnestesiologia.PublicadoporElsevierEditoraLtda.Este ´eum artigoOpen Accesssobumalicenc¸aCCBY-NC-ND( http://creativecommons.org/licenses/by-nc-nd/4.0/).
Introduction
Takotsubocardiomyopathy(TCM),firstdescribedin1990in theJapanese population, is a cardiomyopathy induced by physicaloremotionalstress.1Itischaracterizedbyanacute onsetofsymptomsandelectrocardiographicabnormalities mimicking an acute coronary syndrome (ACS). Although theremaybeaslightriseinenzymesofmyocardialinjury, thereisnoobstructivecoronaryarterydisease(CAD)andthe clinicalpresentationrevertscompletelyindaysorweeks.2---4 TCM designation comes from the occurrence of transient dysfunctionoftheleftventricle(LV).Theappearanceofthe LVduringsystoleresemblesatakotsubo(Japaneseceramic potwithroundedbaseandnarrowneck,tsubo;usedtotrap octopus,tako).This morphologyisdue tomesoventricular akinesisandapicalandbasalventricularhyperkinesis (nar-rowatthebaseandwithapicalbulging).2,5
Withthegrowingnumberofcasesreportedworldwide, other names has been proposed, justified by the cardiac morphologyandclinicalpresentationcontext:apicalbulging syndrome,transient left ventriculardysfunction with api-cal bulging, broken heart syndrome, and, more recently, transient left ventricular apical akinesia/dyskinesia or stress-inducedcardiomyopathyaresomeofatotalof75 dif-ferentnames. However,theinitial nameseems tobethe mostappropriate, asitis comprehensive enough toallow theadditionofnewvariants,remindsusofthechangesin LVmorphologyand isrecognition ofthe investigatorswho firstdescribedit.5
The true prevalence of TCM remains unclear, but it is estimated to correspond to 1%---2% of cases in which thereis clinicalsuspicionofACS; itpredominantlyaffects
women in the postmenopausal period, between 62 and 76years.2,4,6
ForTCM diagnosis, a high indexof clinical suspicion is needed aswell asdiagnostic testssuch as echocardiogra-phy and cardiac catheterization, in addition to ECG and myocardialinjurymarkersthatareessential. Echocardiog-raphy allows the verification of the typical changes in LV segment contractility. And cardiac catheterizationproves theabsenceofsignificantcoronarychanges.2,6Several diag-nosticcriteriahave beenproposed.The most widelyused aretheMayoCliniccriteria(Table1).7
Despite the lack of a clear, singular, andunambiguous explanationoftheTCMpathophysiology,theunderlying eti-ologicmechanismshavebeen thesubjectofmany studies
Table1 Diagnosticcriteria(MayoClinic).7
• Hypokinesia,transientdyskinesiaorakinesiainLVmid
andapicalsegments,withorwithoutapicalinvolvement,
withimpairedcontractilityofthevascularizationarea
correspondingtomorethanonecoronaryartery
• NoobstructiveCADorangiographicevidenceofacute
plaquerupture
• Electrocardiographicchangesdenovo(STsegment
elevationand/orT-waveinversion)and/orslightincrease
inserumtroponinlevels
• Nopheochromocytomaandmyocarditis
Itdoesnotincludecriteriasuchasage,genderand
presenceoftriggeringfactor,aswellasdocumentation
andseveraltheorieshave beenproposed,suchasthe car-diotoxicityassociatedwithcatecholamine, theoccurrence of coronary spasm,microvascular ischemia, cardiac auto-nomic instability, isolated plaque rupture in the anterior descending coronaryartery,and/or acute obstruction and dynamicLVoutflowtract.2
There is no standard treatment for these patients because of its reversibility and pathophysiological uncer-tainty. In the acutephase, the treatment is symptomatic withsupportivetherapyaccordingtothedegreeofsystolic dysfunction anddirected to the acutecomplications that occurinapproximately20%ofpatients,whichincludeacute lungedema,arrhythmia,embolism,cardiogenicshock,and death.2,6
Intheabsenceofcomplications,theprognosisisusually benign, with full recovery of ventricular function, com-pletedisappearanceofsymptomsandelectrocardiographic changesandventricularmotionabnormalitiesand normal-izationofmyocardialinjurymarkers.Althoughthisrecovery occursinaperiodof about6---8 weeks,the electrocardio-graphic tracingcantake yearstonormalize.2,5 Inpatients whoserecoveryiscomplete,long-termsurvivalissimilarto thegeneralpopulation.RecurrenceofTCMislessthan10%, andaprolongedfollow-upisrecommended.
Any anesthetic-surgicaleventbeing definedasa physi-calandemotionalstresssituationrequiresthatallpatients withconfirmeddiagnosisoftakotsubosyndromehaveclose monitoringandspecialcareduringtheperioperativeperiod.
Case
report
Female patient, 55 years old, white, 60kg, sched-uled for elective segmental colectomy for angiodysplasia of the colon, with recurrent episodes of lower gas-trointestinal bleeding. The patient reported history of ischemicstroke withright hemiparesissequelaofbrachial predominance,hypertension,type2diabetesmellitus, dys-lipidemia, and takotsubo syndrome diagnosed two years earlieraftersuspectedACSwithoutSTelevation(excluded by cardiac catheterization with normal coronary arter-ies and complete clinical resolution after three days). The patient was taking allopurinol 300mg, omeprazole 20mg, gabapentin 400mg, simvastatin 40mg, amlodipine 5mg, aspirin 100mg, carvedilol 25mg, lisinopril 20mg, hydrochlorothiazide 12.5mg, furosemide 20mg, and gli-clazide 60mg----medication maintained until the day of surgery.
Inpre-anestheticevaluation,nosignificantchangeswere detected on physical examination or auxiliary diagnostic tests.ShewasclassifiedasASAIII.
Intraoperativemonitoringincluded5-leadECG,invasive bloodpressure,peripheraloxygensaturation,capnography, esophageal temperature, BIS®, neuromuscular block, and urineoutput.
After premedication with midazolam (1mg) and fen-tanyl (0.05mg), a lumbar epidural catheter was placed, as well as an arterial line in the left radial artery. Gen-eral anesthesiawas induced using fentanyl (0.02mgkg−1)
andpropofol(2mgkg−1),andneuromuscularblockadewith
rocuronium(0.6mgkg−1).Anesthesia wasmaintainedwith
sevofluraneforBIS®between40and60,bolusofintravenous
rocuronium,and0.2%ropivacaineepidurally.Anesthesiawas supplementedbybolus followedbyinfusion ofesmololfor heartratesof60---70beatsperminute.
Thepatientremainedhemodynamicallystable through-out the procedure, which was uneventful and lasted two hours. At the end of surgery, neuromuscular block was reversedwithsugammadex(2mgkg−1),andthepatientwas
extubatedwithoutincident.
Afteruneventful2hatPost-anesthesiaCareUnit(PACU) esmololwassuspendedandthepatientwastransferredto theIntermediate Care Unit (IMCU).Postoperative analge-sia was performed with epidural infusion of ropivacaine 1mgmL−1 and sufentanil0.008mcgmL−1 (10.4mLh−1) for
24h.
Conclusion
Despitethegoodprognosisandlowrecurrence,TCMshould not be overlooked due to its serious complications.2,8 Of theacutecomplications,systolicheartfailureis themost common,followedbyheartfailure(fatalifnottreated sur-gically),andotherlesscommon,suchascardiogenicshock (requiring vasopressor and/or intensive inotropic treat-mentorintra-aortic balloonplacement),acutepulmonary edema,atrialorventriculararrhythmias,ventricularseptal defect,orthrombusformationattheLVlevelwithpossible embolism.9,10 Thesecomplicationsareresponsiblefor pro-longedandrecurrenthospitalizations,aswellasmortality associatedwiththissyndrome.2,8
Thephysiological mechanismrelatingtheperioperative stress with TCM is still unclear because of its multifac-torial pathogenesis and because its true etiology remain unknown.2Althoughsometimesnotriggeringfactoris iden-tified,theassociationwithemotionaland/orphysicalstress arisesinabouttwo-thirdsofpatientswhodevelopTCM.11---13 Currently, the most accepted etiology related stress stimulitothesignificantincreaseincatecholaminerelease by increased sympathetic stimulation. This can cause myocardialadrenergic stimulationandconsequent change in contractility and transient heart dysfunction.2,3,8 The stress inducingstimulation of the limbic system can lead to excitation of medullary centers of autonomic nervous system, which will encourage presynaptic and postsynap-ticneuronsandleadtothereleaseofnoradrenalineandits neuronalmetabolites;atthesametimethatstimulationof theadrenal medulla occursand thereleaseof adrenaline isinduced.Throughcardiacandextra-cardiacsympathetic nerves,aswellasbloodstream,thesecatecholamines stim-ulatethe heart by bindingtoadrenergic receptors of the vesselsandinducetoxicityincardiomyocytes.Toxicitymay beexercised inanindirect waybycoronaryspasmand/or microvascularalterations,ordirectly byexcessofcalcium and free radical production.2,3,14 Patients with TCM have supra-physiologicallevels of plasma catecholamines, with significant increases of epinephrine and norepinephrine, amongothersneurotransmitters,consistentwithincreased synthesisandreuptake.11,14
catecholamines,which begins inthe preanesthetic period andendswithinthreetofourdayspostoperatively.15,16 How-ever,aclearexplanationforthisindividualsusceptibilityto cardiomyopathyafterexposuretoasimilardegreeofstress is unknown; it is possible due toa genetic heterogeneity associated with adrenergic receptors, which makes them moreorlesssensitivetostimuli.16
Thereis noanesthetic-surgical strategyclearlydefined in the literature to prevent the recurrence of takotsubo cardiomyopathyinpatientsrequiringsurgicalintervention. However,thelowestpossiblestimulationandrigorous mon-itoringforearlydiagnosisofaprobableacutecomplication during the perioperative period appear to be the safest options.17,18
Ideally,thistypeofpatientshouldonlybeoperatedupon inhospitalswithcardiologyservice,withhemodynamicunit andintensivecoronarycare.Althoughthereisnoabsolute consensus, one should choose regional anesthesia, which canmitigatethereleaseofcatecholaminesassociatedwith thesurgicalstress,intubationandextubation,inadditionto provideexcellentpostoperativeanalgesia.General anesthe-sia,whichhastheadvantageofpatient’sunconsciousness, maybereplacedbysupplementationofregionalanesthesia withsedation.15,19
In the preoperative period, the timebefore the surgi-cal procedure itself and the emotional imbalance should beminimizedtoprovideadeeperlevelofanxiolysis,using pharmacologicalandpsychologicalapproaches, beforethe patientistakentotheoperatingroom.15,17---20 Prophylactic -blocker therapy appears to be useful to prevent acute stress, reducing the emotional impact of surgery in the functionalstatusofthepatient.Thus,ifthereareno con-traindications,itshouldbegiventothesepatients;however, itremainsunclearwhatdosageisrequiredtoblockthehigh levelsofcatecholaminesandifthereisanysignificant differ-encebetweendifferent-blockers.8,15,19Studiesinanimals suggest thatboth ␣ and -blockingagents may normalize theelectrocardiographicchangesinducedbystress.21
Intraoperative and postoperative monitoring shouldbe careful.Itisrecommendedcontinuousmonitoringof inva-sive blood pressure via arterial catheterand, if possible, intraoperativemonitoringof leftventricular functionwith transesophagealechocardiographywhenusinggeneral anes-thesia.ECGmonitoringshouldbeperformedwith5-lead.
Inordertopreventsympatheticstimulationand exces-sive release of catecholamines, laryngoscopy should be brief, awakening and extubation should be smooth, and residual neuromuscular blockade should be avoided. The anestheticagents ofchoice,both for induction and main-tenance,shouldbethosewithlesspotentialofmyocardial depressiontoavoidhemodynamic instability.An adequate controloffluidavoidingvolumeoverloadisrecommended, aswellasagoodpaincontrol.15,19
In the above mentioned clinical case, the anesthetic planincludedabalancedgeneralanesthesiacombinedwith thoracicepidural.Theobjectivewastodecreasethe sympa-theticresponseinherenttothistypeofabdominalsurgery, classicallyclassifiedasmajor.Allpreoperativecarewas per-formed,including-blocking,amedicationthatthepatient was already taking. Postoperatively, there was constant monitoringinIMCU,anditwasfoundthatepiduralinfusion ofalocalanesthetichasprovidedaneffectiveanalgesia.
There is question about if this was a successful case, giventheperioperativeapproach,orjustafluke.However, itisimportanttonotethatanypatientdiagnosedwithTCM undergoingsurgeryrequiresanindividualizedperioperative approachtoavoidapossiblerecurrenceandfataloutcome causedbyoneofitsacutecomplications.
Giventhe rarity of TCM,it is important toexposeand discusstheanestheticmanagementofanypatientwiththis disease and contributeto clarifying the bestprophylactic andanestheticapproachinsuchpatients.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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