A concealed case of takotsubo syndrome as consequence of ab ingestis episode in a revascularized patient

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We report the case of secondary Takotsubo syndrome as a consequence of an ingestis episode in an elderly woman with a history of myocardial revascularization and ischemic stroke with residual emiparesis and dysphagia. Particularly, the invasive coronary angiography showed the left internal mammary artery bypassing a myocardial bridge in the context of a non-severely stenotic coronary artery disease (CAD). Moreover, atypical biventricular wall motion abnormalities were found at the first echocardiographic assessment. We hypothesize that post-ischemic dysphagia may lead to cardiac consequences likely comparable to those of near-drawing syndrome, even though in this specific case a concomitant linked mechanism to myocardial bridging cannot be excluded.
Afterwards, during dinner-time the patient had an episode of food aspiration into the airways and started to experience intense dyspnea. At hospital admission, she was apyretic, presented dyspnea and respiratory failure (PaO2 60 mmHg), sinus tachycardia and had pulmonary rales bilateraly. Arterial blood pressure was 130/95 mmHg. Laboratory exams showed mild troponin I concentration raise (tnI 2.43 ng/ml) and neutrophilic leukocytosis (24.79 × 103/μl). The ECG showed sinusal tachycardia and mild ST-segment elevation (max 2 mm) in precordial leads (Fig. 1). Chest radiograph showed interstizial-alveolar bilateral congestion and thoracic computed tomography demonstrated the presence of numerous bilateral infiltrates of ‘flowering tree’ type.
TTE was promptly performed and showed the presence of biventricular wall motion abnormalities characterized by akinesia of apex, mid anterior wall, mid septum of the LV, and right ventricular apex and mid right free wall, hypokinesia of mid inferior, posterior and anterolateral wall of the LV with consequent severe systolic disfunction (LVEF of 26%) (Fig. 2).
The patient refused to undergo invasive coronary angiography (ICA) at admission and was treated with diuretics with prompt resolution of the pulmonary edema. A subsequent radiograph of the chest showed a new pulmonary focus compatible with clinically suspected pneumonia ‘ab ingestis’. The ECGs performed on second and third days showed the progressive resolution of ST-segment elevation, and elongation of QT interval (Fig. 1). The level of cardiac tnI after the peak (2.43 ng/ml) at the time of admission showed a progressive reduction. Subsequently, the patient accepted to undergo ICA which demonstrated a nonseverely stenotic CAD and a short intramyocardial course of left anterior descending (Fig. 3).
Thanks to support therapy the clinical condition of the patient improved soon and the ultimate TTE control showed a complete normalization of kinetic and LVEF.

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