Author + information
- Received March 21, 2016
- Revision received March 29, 2016
- Accepted April 7, 2016
- Published online June 27, 2016.
- Ahmed Harhash, MDa,∗ (, )
- Konstantinos P. Koulogiannis, MDb,
- Leo Marcoff, MDb and
- Robert Kipperman, MDb
- aDepartment of Medicine, Morristown Medical Center, Morristown, New Jersey
- bDepartment of Cardiology, Morristown Medical Center, Morristown, New Jersey
- ↵∗Reprint requests and correspondence:
Dr. Ahmed Harhash, Morristown Medical Center, Department of Medicine, 100 Madison Avenue, Morristown, New Jersey 07960.
An 84-year-old woman underwent successful transfemoral transcatheter aortic valve replacement (TAVR) using a 26-mm CoreValve Evolut R (Medtronic, Minneapolis, Minnesota). Intraoperative transesophageal echocardiography confirmed normal valve position and normal left ventricular function. Trace paravalvular regurgitation was detected. The procedure was well tolerated, and the patient was extubated the same day. Transthoracic echocardiography the following day confirmed normal CoreValve Evolut function and normal biventricular function (Figures 1 and 2, Online Video 1).
On post-operative day 2, the patient developed sudden-onset chest pain and severe hypotension. There were no inciting factors or stressors. Electrocardiography showed new ST-segment elevations and T-wave changes compared with baseline electrocardiography. The cardiac troponin I level was 0.239 ng/ml. Transthoracic echocardiography demonstrated severe biventricular apical hypokinesis and normal TAVR function (Figures 3 and 4, Online Video 2). Coronary angiography did not reveal significant obstructive coronary artery disease (Figure 5). Repeat electrocardiography showed anterior T-wave inversions with the development of Q waves. Follow-up troponin I peaked at 2.54 ng/ml and then decreased to 1.9 ng/ml over 24 h. There was an initial period of cardiogenic shock requiring vasopressor support that was followed by clinical resolution within 48 h. Follow-up transthoracic echocardiography 3 days following angiography demonstrated near normalization of left ventricular apical wall motion. Stress-induced/takotsubo cardiomyopathy was suspected on the basis of 4 diagnostic criteria (1): 1) transient abnormality in left ventricular wall motion beyond a single coronary artery perfusion territory; 2) absence of obstructive coronary artery disease; 3) new electrocardiographic abnormalities or elevation in cardiac troponins; and 4) absence of pheochromocytoma and myocarditis.
TAVR is a less invasive procedure than conventional cardiac surgery, but it may entail significant physical stress for high-risk patients. Myocardial ischemia during and immediately after TAVR has been described (2), but this case represents a unique presentation of stress-related cardiomyopathy.
For supplemental videos and their legends, please see the online version of this article.
The authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received March 21, 2016.
- Revision received March 29, 2016.
- Accepted April 7, 2016.
- American College of Cardiology Foundation