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 Table of Contents  
Year : 2021  |  Volume : 5  |  Issue : 2  |  Page : 169-172

Role of Echocardiography in Managing a Rare Case of Reverse Takotsubo Cardiomyopathy Presenting as Cardiogenic Shock after Prolonged Hip Surgery

1 Department of Cardiology, Yashoda Hospital, Hyderabad, Telangana, India
2 Department of Critical Care Medicine, Yashoda Hospital, Hyderabad, Telangana, India
3 Department of Internal Medicine, Yashoda Hospital, Hyderabad, Telangana, India

Date of Submission08-Oct-2020
Date of Acceptance28-Mar-2021
Date of Web Publication09-Jun-2021

Correspondence Address:
Dr. Pankaj Jariwala
Department of Cardiology, Yashoda Hospital, Somajiguda, Hyderabad - 500 082, Telangana
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_68_20

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One of the major causes of reversible left ventricular (LV) systolic dysfunction is takotsubo cardiomyopathy. It is characterized by angina, dyspnea, electrocardiogram changes (ST segment elevation and T wave changes on chest leads of electrocardiogram), echocardiographic changes (LV dysfunction with predominant apical involvement), elevation of troponin and brain natriuretic peptide, usually mimicking acute coronary syndrome. Coronary angiogram in such cases is either normal or shows only insignificant coronary disease. Although LV apical involvement is the commonest manifestation, about one-fifth of cases of takotsubo cardiomyopathy have normal apical contractility but severe systolic dysfunction of the basal segments of the left ventricle. We report a case of reverse takotsubo cardiomyopathy developed in a relatively young patient following hip surgery and how three-dimensional and strain echocardiography clearly demonstrated the abnormality and aided the recovery of the patient.

Keywords: Advanced echocardiography, broken-heart syndrome, reversible ventricular dysfunction, strain echocardiography, stress cardiomyopathy, takotsubo cardiomyopathy, three-dimensional echocardiography

How to cite this article:
Jadhav KP, Jariwala P, Mishra KC, Boorugu HK. Role of Echocardiography in Managing a Rare Case of Reverse Takotsubo Cardiomyopathy Presenting as Cardiogenic Shock after Prolonged Hip Surgery. J Indian Acad Echocardiogr Cardiovasc Imaging 2021;5:169-72

How to cite this URL:
Jadhav KP, Jariwala P, Mishra KC, Boorugu HK. Role of Echocardiography in Managing a Rare Case of Reverse Takotsubo Cardiomyopathy Presenting as Cardiogenic Shock after Prolonged Hip Surgery. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2021 [cited 2021 Nov 29];5:169-72. Available from: https://www.jiaecho.org/text.asp?2021/5/2/169/318102

  Introduction Top

“Humankind cannot bear so much stress of reality”

-T. S. Elliot

Reverse takotsubo cardiomyopathy (rTTC) is a variant of takotsubo cardiomyopathy (TTC) characterized by reversible left ventricular (LV) dysfunction presenting as hypokinesis of basal segments and apical hyperkinesis on echocardiography with spontaneous recovery. Clinically, acute coronary syndrome (ACS) is very similar to rTTC with regards to symptoms (angina-like chest pain, syncope, epigastric pain, and indigestion), changes in electrocardiography (T-wave inversion, ST-segment elevation, prolonged QT interval, and new bundle branch block), high troponin values and LV dysfunction. The diagnostic test differentiating them is the normal epicardial coronary artery on the angiogram seen in rTTC.[1] Epidemiologically, the younger people are affected by rTTC (mean age 36 years) and rTTC constitutes up to 23% of total TTC patients.[2] Two-dimensional (2D) and strain echocardiography are important tools in the diagnosis, prognostication and follow-up of TTC and its variants.[3] The role of three-dimensional (3D) echocardiography is not clearly defined and there are scarce publications in this field. We present a case of rTTC where advanced echocardiography was used for diagnosing the condition, delineating the pattern of LV dysfunction and for confirming the response to the treatment and follow-up of the case.

  Case Report Top

A 45-year-old male patient with a history of bilateral total hip replacement (THR) done for steroid-induced avascular necrosis 8 years ago, underwent revision THR of right hip at an outside hospital. Preoperative examination and cardiac evaluation were normal. He suffered massive blood loss (“Advanced Trauma Life Support” class-IV) intraoperatively, requiring 5 units of packed red blood cells and 2 units of fresh frozen plasma transfusion. Postoperatively, the patient had chest pain and hypotension which was managed with inotrope support (noradrenaline). Screening echocardiography revealed severe LV systolic dysfunction; therefore, he was referred to us for further management.

On presentation, he had a heart rate of 134/min, regular; systolic blood pressure (BP) of 70 mmHg on noradrenaline and dobutamine infusion. All peripheral pulses were felt and pulse oximeter showed a saturation of 90% on 4 L/min of oxygen. Electrocardiogram of the patient showed sinus tachycardia with strain pattern and <2 mm ST elevation in I and aVL leads. Echocardiography revealed severe LV systolic dysfunction (ejection fraction [EF]:15%–20%) with apical segments contracting better than basal segments. The laboratory examination showed hemoglobin of 15.1 g/dL, leukocytosis (18,900 cells/mm3), elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) of 1248 pg/mL, high-sensitivity troponin I value of 2.0 ng/mL (normal range – 0.0–0.12 ng/mL) and serum creatinine of 1.3 mg/dL. With a provisional diagnosis of shock secondary to hypovolemia and cardiac dysfunction, he was admitted to intensive care unit (ICU). ACS or stress-cardiomyopathy was the differential diagnosis for severe LV systolic dysfunction. He was started on antiplatelets, anticoagulants (enoxaparin), trimetazidine, statin and prophylactic third generation antibiotic 'cephaperazone'. In view of respiratory failure, the patient was intubated immediately after admission, and placed on a ventilator. Additional investigations revealed signs of sepsis with elevated procalcitonin of 11.17 ng/mL, elevated total white cell count and homogenous bilateral lung patches in the lower lobes; thus, antibiotics were upgraded to imipenem + cilastatin and teicoplanin. A repeat troponin-I levels showed an acute increase to 37.8 ng/mL. Once his blood pressure rose to 90/60 mmHg with inotropic support, he underwent coronary angiogram which revealed normal epicardial coronaries. This finding was highly suggestive of rTTC being the underlying diagnosis. The noradrenaline and dobutamine inotropes were slowly weaned off and levosimendan inotrope was administered to maintain blood pressure for next 24 hours. Because of the severe nature of the cardiogenic shock, intra-aortic balloon pressure (IABP) was inserted through the left femoral artery and BP was augmented with a 1:1 ratio. Over the next 48 hours, all metabolic and electrolyte abnormalities were managed as required; blood and endotracheal tube cultures failed to show any growth. Leukocytosis improved to 15,500 cells/mm3; serum lactate improved from 3.0 to 0.89 mmol/L. The IABP support was gradually weaned, with augmentation ratio reduced from 1:1 to 1:3, and eventually removed as BP improved to 110/70 mmHg. The patient was initiated on small doses of oral beta-blocker (carvedilol) and diuretic infusion (furosemide), which were gradually titrated-up as blood pressure remained stable. The patient was shifted for a detailed echocardiographic evaluation, where 3D and strain echocardiography were performed [Figure 1] and [Figure 2]. This assessment revealed improved LVEF to 45% [Video 1] and [Video 2]. Strain imaging performed using 2D speckle tracking showed reduced regional strain in basal and mid segments of all the walls, but significantly so in anteroseptal and inferoseptal walls. The apical segments showed excellent strain readings [Figure 3] and [Figure 4]. These exact findings were mirrored by 3D imaging of all 17 LV segments. This aided us in up-titrating the medication and shifting the patient out of ICU on day 6. Later, he was discharged in a stable condition with BP of 100/70 mmHg.
Figure 1: Three-dimensional echocardiography during the acute illness, showing impaired contractility of left ventricular basal segments. (a) Early systole, (b) end systole (impaired contraction of the basal segments can be noted), (c) early diastole, and (d) late diastole

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Figure 2: Three-dimensional echocardiography during follow-up showing improved contractility of the initially affected left ventricular basal segments. (a) Early systole, (b) end systole, (c) early diastole, and (d) late diastole

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Figure 3: Strain echocardiography showing left ventricular segmental longitudinal strain during the acute illness. (a) Bull's eye display of the strain values in all the left ventricular segments, (b) strain values in the apical four-chamber view, (c) strain values in the apical two-chamber view, and (d) strain values in the apical three-chamber view

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Figure 4: Strain echocardiography showing left ventricular segmental longitudinal strain in post-recovery state. (a) Bull's eye display of the strain values in all the left ventricular segments, (b) strain values in the apical four-chamber view, (c) strain values in the apical two-chamber view, and (d) strain values in the apical three-chamber view

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[Additional file 1]

Video 1: Full volume three-dimensional echocardiography showing reduced left ventricular contractility with regional wall motion abnormality at presentation. This video shows hypokinesia in basal segments of left ventricle.

[Additional file 2]

Video 2: Full volume three-dimensional echocardiography showing left ventricular contractile function and regional wall motion abnormality in post-recovery stage. This video shows improvement of hypokinesia in basal segments of left ventricle.

  Discussion Top

The possible pathophysiology of rTTC includes catecholamines cardiotoxicity, coronary artery spasm, coronary microvascular impairment, and estrogen deficiency (especially in postmenopausal women). The most widely accepted theory involves a mechanism where high catecholamines induce cardiomyopathy, first proven in animal studies, and later in some large human studies which showed significantly higher levels of plasma epinephrine in rTTC patients.[4] Another theory involves microvascular impairment in patients with rTTC leading to vasoconstriction and reduced myocardial perfusion causing LV dysfunction.[5] Severe LV systolic dysfunction can lead to common complications such as cardiogenic shock; also rarely ventricular septal perforation and septal dissection, which can be catastrophic.[6]

When compared to TTC, rTTC affects relatively younger patients, has higher troponin and natriuretic peptide values, very low LV-EF at presentation, and quick recovery.[7] This is usually precipitated by acute physical and emotional stress. In our case, the precipitating factors included major surgery of a hip joint, acute massive blood loss, tachycardia and underlying sepsis. After a thorough search of the literature, several articles on TTC following hip surgery were found, but none on rTTC. Thus, this case of rTTC following hip surgery is extremely rare.

Previous studies have shown higher in-hospital mortality and higher incidence of major adverse cardiac events with worse basal-lateral strain (< -10%), mid-lateral strain (< -7%), and global longitudinal strain values.[8] However, our patient had strain of >-10% in basal-lateral and strain of >-7% in mid-lateral LV segments and maximum strain reduction was observed in basal-anterior and basal-septal segments. Thus, strain echocardiography allowed for detailed delineation of the LV dysfunction pattern in our patient with rTTC. Furthermore, strain echocardiography can be a strong predictor of morbidity and mortality,[9],[10]

The European Association of Cardiovascular Imaging and the Japanese Society of Echocardiography joint statement reaffirms the role of cardiac magnetic resonance imaging (cMRI) in TTC. Many studies have shown that 3D echocardiography correlates very well with cMRI. Therefore, 3D echocardiography can be a good alternative to cMRI in ICU patients in whom cMRI may not be feasible.[11]

Some of the peculiarities and uniqueness of our case are that following hip surgery, a relatively young patient developed rTTC. Furthermore, the possible aggravating role of acute blood loss in the development of rTTC. During cardiogenic shock, the use of levosimendan as inotrope and stopping noradrenaline and dobutamine helped in quick recovery of LV function, especially because of catecholamine surge being the cause for TTC and rTTC.[12] The continued use of catecholamines could have deteriorated the LV function further. The use of IABP along with levosimendan would have improved the coronary flow, especially during the diastolic phase thus improving the ischemic myocardium to recover faster. Finally, the use of 3D echocardiography and strain imaging aided in mapping the LV segmental dysfunction which could help in up-titrating cardiac medications such as beta-blockers, angiotensin converting enzyme inhibitors inhibitors, and diuretics.

  Conclusion Top

rTTC is a rare cardiac ailment, hardly reported among hip replacement patients. Its proper management usually yields very good results with reduced morbidity. The use of 3D and strain echocardiography may help in accurately measuring LV function, quantification of absolute cardiac chamber volumes and map severity of LV segment dysfunction, thus aiding in prognostication and modifying cardiac medications. The use of levosimendan and IABP for faster recovery of LV function should be stressed.


We would like to thank Ms. B Sujatha and Ms. Anjali Deepa, echocardiography technicians at Yashoda Hospital, Somajiguda, Hyderabad.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Awad HH, McNeal AR, Goyal H. Reverse Takotsubo cardiomyopathy: A comprehensive review. Ann Transl Med 2018;6:460.  Back to cited text no. 1
Ramaraj R, Movahed MR. Reverse or inverted takotsubo cardiomyopathy (reverse left ventricular apical ballooning syndrome) presents at a younger age compared with the mid or apical variant and is always associated with triggering stress. Congest Heart Fail 2010;16:284-6.  Back to cited text no. 2
Izumo M, Akashi YJ. Role of echocardiography for takotsubo cardiomyopathy: Clinical and prognostic implications. Cardiovasc Diagn Ther 2018;8:90-100.  Back to cited text no. 3
Kumai T, Inamasu J, Watanabe E, Sugimoto K, Hirose Y. Differences between Takotsubo cardiomyopathy and reverse Takotsubo cardiomyopathy associated with subarachnoid hemorrhage. Int J Cardiol Heart Vasc 2016;11:99-103.  Back to cited text no. 4
Milinis K, Fisher M. Takotsubo cardiomyopathy: Pathophysiology and treatment. Postgrad Med J 2012;88:530-8.  Back to cited text no. 5
Mariscalco G, Cattaneo P, Rossi A, Baravelli M, Piffaretti G, Scannapieco A, et al. Tako-tsubo cardiomyopathy complicated by ventricular septal perforation and septal dissection. Heart Vessels 2010;25:73-5.  Back to cited text no. 6
Tagami T, Mertens A, Rothschild D, Chowdhury P. A case of reverse takotsubo cardiomyopathy caused by an eating disorder. J Cardiol Cases 2017;15:77-9.  Back to cited text no. 7
Dias A, Franco E, Rubio M, Bhalla V, Pressman GS, Amanullah S, et al. Usefulness of left ventricular strain analysis in patients with takotsubo syndrome during acute phase. Echocardiography 2018;35:179-83.  Back to cited text no. 8
Stanton T, Leano R, Marwick TH. Prediction of all-cause mortality from global longitudinal speckle strain: Comparison with ejection fraction and wall motion scoring. Circ Cardiovasc Imaging 2009;2:356-64.  Back to cited text no. 9
Tanaka H, Nesser HJ, Buck T, Oyenuga O, Jÿnosi RA, Winter S, et al. Dyssynchrony by speckle-tracking echocardiography and response to cardiac resynchronization therapy: Results of the Speckle Tracking and Resynchronization (STAR) study. Eur Heart J 2010;31:1690-700.  Back to cited text no. 10
Citro R, Okura H, Ghadri JR, Izumi C, Meimoun P, Izumo M, et al. Multimodality imaging in takotsubo syndrome: A joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE). Euro Heart J Cardiovasc Imaging 2020;21:1184-207.  Back to cited text no. 11
Yaman M, Arslan U, Kaya A, Akyol A, Ozturk F, Okudan YE, et al. Levosimendan accelerates recovery in patients with takotsubo cardiomyopathy. Cardiol J 2016;23:610-5.  Back to cited text no. 12


  [Figure 1], [Figure 2], [Figure 3], [Figure 4]


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