DISCUSSION
In 2007 Itoh et al.[2] described the first intraoperative case of TS following cardio-pulmonary bypass. This was hypothesized to be caused by direct myocardial damage during the operation or a stunning subsequent to a huge catecholamines relapse [3].
In our case, probably, we had three concomitant precipitating factors: the emergency conversion to full sternotomy, the post-weaning tonic-clonic seizure and the consequent hemodynamic instability and need for high dose vasopressors agents.
Takotsubo syndrome has been classified as a transient and benign disease.[4] However, recent studies indicated that some critical complications and sudden death may occur, especially when right ventricle failure is associated.[5]
Therefore it should be considered in the differential diagnosis of patients developing sudden cardiogenic shock after surgery.
In this case, given the anatomical characteristics of a repaired mitral valve with mixomatous leaflets we had to deal not only with a disfunctioning LV but also with a SAM causing severe mitral insufficiency, pulmonary hypertension and RV failure. The management of this peculiar combination is particularly challenging, especially in the acute phase. On one hand the treatment of SAM normally involves aggressive volume loading and beta-adrenoceptor blockade, but on the other hand right ventricle function can deteriorate once this is provided, especially with the coexistence of pulmonary hypertension. Even though inotrope administration is contraindicated in patients with SAM, we found that in the acute phase levosimendan, noradrenaline and low dosages of adrenalin were helpful to sustain hemodynamics. We observed that adding esmolol to reach a heart rate between 85 and 100 bpm provided the best balance for this delicate situation. Probably, simultaneous inotropic support with low adrenalin and noradrenaline dosages and inhaled NO contributed to improve right ventricle function despite the aggressive fluid administration.
In conclusion, even though it is complex to deal with two conditions which normally require treatments that collide (SAM and right ventricle dysfunction), we believe that recognizing takotsubo syndrome and finding a good balance between betablockers, inotropes, fluid administration and inhaled NO is crucial and can be life-saving for the patient.