Case report of atypical takotsubo cardiomyopathy complicated by cardiogenic shock

Introduction. The diffuse form of takotsubo cardiomyopathy is extremely rare and even less frequently differentiated from other syndromes. Nevertheless, prompt identification of this condition and a correct emergency care protocol will facilitate proper treatment and minimize complications.

Objective. To describe a case of successful use of veno-arterial extracorporeal membrane oxygenation in a patient with cardiogenic shock due to a rare biventricular form of takotsubo cardiomyopathy.

Material and methods. The patient, a 55-year-old man, without previous history of chronic disease, was admitted for an abruptly arising atypical form of takotsubo syndrome. The clinical Case Report description utilized laboratory and instrumental tests results from the patient's medical record.

Results. The characteristics of the clinical course of the atypical takotsubo syndrome complicated by cardiogenic shock, and the treatment outcomes have been presented.

Conclusions. This clinical case review has demonstrated that the Takotsubo syndrome can manifest itself as a diffuse biventricular dysfunction, leading to a life-threatening cardiogenic shock. A multimodal approach using echocardiography, coronary angiography, and cardiac magnetic resonance imaging played an important role in differential diagnosis to distinguish the disease from an acute coronary syndrome and myocarditis. Mechanical circulatory support served as a successful strategy for a rapid and adequate restoration of cardiac contractility. There is a need for heightened vigilance regarding atypical forms of takotsubo syndrome in patients with cardiogenic shock and non-obstructive coronary arteries.

1. Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J Cardiol. 1991;21(2):203–214. PMID: 1841907

2. Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008;155(3):408–417. PMID: 18294473 https://doi.org/10.1016/j.ahj.2007.11.008

3. Templin C, Ghadri JR, Diekmann J, Napp LC, Bataiosu DR, Jaguszewski M, et al. Clinical features and outcomes of takotsubo (stress) cardiomyopathy. N Engl J Med. 2015;373(10):929–938. PMID: 26332547 https://doi.org/10.1056/NEJ-Moa1406761

4. Schweiger V, Cammann VL, Crisci G, Gilhofer T, Schlenker R, Niederseer D, et al. Temporal trends in Takotsubo syndrome: results from the International Takotsubo Registry. J Am Coll Cardiol. 2024;84(13):1178–1189. PMID: 39217551 https://doi.org/10.1016/j.jacc.2024.05.076

5. Ghadri JR, Wittstein IS, Prasad A, Sharkey S, Dote K, Akashi YJ, et al. International Expert Consensus Document on Takotsubo Syndrome (Part I): clinical characteristics, diagnostic criteria, and pathophysiology. Eur Heart J. 2018;39(22):2032–2046. PMID: 29850871 https://doi.org/10.1093/eurheartj/ehy076

6. Ghadri JR, Cammann VL, Jurisic S, Seifert B, Napp LC, Diekmann J, et al. A novel clinical score (InterTAK Diagnostic Score) to differentiate takotsubo syndrome from acute coronary syndrome: results from the International Takotsubo Registry. Eur J Heart Fail. 2017;19(8):1036–1042. PMID: 27928880 https://doi.org/10.1002/ejhf.683

7. Fröhlich GM, Schoch B, Schmid F, Keller P, Sudano I, Lüscher TF, et al. Takotsubo cardiomyopathy has a unique cardiac biomarker profile: NTproBNP/myoglobin and NT-proBNP/troponin Tratios for the differential diagnosis of acute coronary syndromes and stress induced cardiomyopathy. Int J Cardiol. 2012;154(3):328–332. PMID: 22044675 https://doi.org/10.1016/j.ijcard.2011.09.077

8. Ghadri JR, Wittstein IS, Prasad A, Sharkey S, Dote K, Akashi YJ, et al. International Expert Consensus Document on Takotsubo Syndrome (Part II): diagnostic workup, outcome, and management. Eur Heart J. 2018;39(22):2047– 2062. PMID: 29850820 https://doi.org/10.1093/eurheartj/ehy077

9. Subbaraman S, Rajan SC, Veeraiyan S, Natarajan P. Takotsubo cardiomyopathy: role of cardiac MRI. J Radiol Case Rep. 2021;15(6):26–32. PMID: 34276878 https://doi.org/10.3941/jrcr.v15i6.4138

10. Alieva AM, Reznik EV, Khachirova EA, Svetlakov VI, Teplova NV, Butorova EA, et al. Takotsubo cardiomyopathy in a 78-yearold woman: case report. Russian Medical Inquiry. 2025;9(1):85–92. (In Russ.). https://doi.org/10.32364/2587-68212025-9-1-11

11. Kato K, Di Vece D, Kitagawa M, Yamamoto K, Aoki S, Goto H, et al. Cardiogenic shock in takotsubo syndrome: etiology and treatment. Cardiovasc Interv Ther. 2024;39(4):421–427. PMID: 39039401 https://doi.org/10.1007/s12928-024-01031-3