A 62-year-old woman undergoing embolization of recurrent neuroendocrine tumor, positive for serotonin, developed chest pain and bradycardia with lateral ST-segment depression. Cardiac biomarkers were elevated, and echocardiography revealed akinesis of all basal segments with a normally contracting apex. The absence of flow-limiting coronary disease on angiography confirmed the presence of reverse Takotsubo cardiomyopathy. After optimal medical therapy for six weeks, left ventricular function returned to normal. Takotsubo cardiomyopathy has been described across a wide variety of hyperadrenergic states; the description of the reverse-type Takotsubo cardiomyopathy in the setting of embolization of recurrent neuroendocrine with serotonergic positivity tumour is novel.
A 62-year-old woman undergoing embolization of recurrent serotonergic neuroendocrine tumor developed chest pain with lateral ST depression. Cardiac biomarkers were elevated, and echocardiography revealed akinesis of all basal segments with a normally contracting apex. The absence of flow-limiting coronary disease on angiography confirmed the presence of reverse Takotsubo cardiomyopathy. The description of reverse-type Takotsubo cardiomyopathy in this setting is novel.
A 62-year-old woman undergoing angiographic bland embolization of the right hepatic artery by interventional radiology service for liver metastases from a previously resected neuroendocrine tumor of the pancreas, which stained positive for serotonin, developed severe chest and epigastric pain radiating to the back during the procedure. She had been pretreated with octreotide. Initial 12-lead electrocardiogram (ECG) revealed sinus rhythm and lateral and inferior ST-segment depression as well as ST elevation in lead aVL (Figure
Initial 12-lead electrocardiogram showing diffuse ST segment depression (predominantly involving the lateral precordial and inferior leads) with minor ST elevation in lead aVL.
Subsequent 12-lead electrocardiogram performed after 24 hours shows resolution of ST segment changes.
Echocardiography was carried out the next day, revealing a normally contracting left ventricular (LV) apex, but akinesis of all basal segments and hypokinesis of the mid-ventricular segments with LV ejection fraction estimated at 40% with no significant valvular dysfunction (Figure
Apical 2-chamber view during systole showing basal hypokinesis and normal apex, the “ace of spades” appearance of left ventricular contractile function.
Left ventricular angiogram showing the “ace of spades” appearance of left ventricular contractile function, with basal hypokinesis and normal apex, consistent with reverse Takotsubo cardiomyopathy.
Takotsubo cardiomyopathy, known variably as apical ballooning syndrome, stress-induced cardiomyopathy, or “broken heart syndrome,” was first described in 1991 and is characterized by severe, reversible LV dysfunction not attributable to flow-limiting coronary artery disease [
The reverse type is rarely described in the literature [
The etiology of Takotsubo cardiomyopathy remains elusive. Sympathetic activity and the role of catecholamines leading to myocardial stunning and toxicity, as well as coronary artery vasospasm, have been implicated, as has estrogen withdrawal [
Takotsubo cardiomyopathy has been described across a wide spectrum of precipitating causes including severe emotional distress or acute medical illness, physical distress (e.g., judo competitions), occult pheochromocytoma, amphetamine use, and the stress and pain associated with elective surgery [
In this case, it is difficult to separate the hyperadrenergic state inherent to the embolization procedure and the role of vasoactive hormones secreted by our patient’s recurrent neuroendocrine tumour as the precipitant of the reverse Takotsubo cardiomyopathy. Her postmenopausal status and the stressful situation of an invasive procedure for recurrent metastatic tumour were clear risk factors. Immunohistochemistry of the primary tumour a year prior revealed focal positivity for serotonin (Figure
Core biopsy of liver, showing metastatic neuroendocrine carcinoma (×10 obj). (A) Hematoxylin/Eosin. (B) Biopsy showing focal positivity for serotonin.
We have described a unique case of reverse Takotsubo cardiomyopathy in the context of angiographic embolization of a recurrent neuroendocrine tumour. Knowledge of this association may be useful in the perioperative, neuroendocrine oncology, and interventional radiology spheres.