R4 Kim, Gene | BMC Radiology

Hi Gene

Another case with death from Takotsubo and Overview of the disease in 8 minutes!

getting close with the streamlining

Clinical Case now on this page Working on overview

Let me know about any reservations or questions

Thanks

re “Sarcoidosis, a Scare, Chest Pain and an Octopus”

Another Case

74-year-old male with type 2 diabetes, CAD s/p stent 6 years prior, hypertension and hypercholesterolemia, fell at home and presents to the ER.
A CXR performed 4 years before, showed no acute cardiopulmonary disease. Healed right sided rib fractures and healed right clavicular fracture were of incidental note

TAKOTSUBO CARDIOMYOPATHY
A CXR performed 4 years before, shows no acute cardiopulmonary disease. Healed right sided rib fractures and healed right clavicular fracture were of incidental note
Ashley Davidoff MD

In the ER a non-displaced right hip fracture was identified and uncomplicated hemiarthroplasty was performed.

ACUTE HIP FRACTURE HEMIARTHROPLASTY
In the ER a non-displaced right hip fracture was identified and uncomplicated hemiarthroplasty was performed.
Ashley Davidoff MD

CXR at the time showed no acute disease

TAKOTSUBO CARDIOMYOPATHY
CXR at the time shows no acute disease
Ashley Davidoff MD

He was discharged and in the interim prior to readmission 2 weeks later his wife fell and had to be admitted to the hospital.
At the time of his next readmission he presented in shock. (NYHA Class IV and ASA Class 4)
CXR showed pulmonary edema.

LA? Difficult to see

Fuzzy Vessels
Perihilar Infiltrates

10, 20 or 30?

Wedge pressure >30

ACUTE CHF
At the time of his next readmission he presented in shock. (NYHA Class IV and ASA Class 4)
CXR showed pulmonary edema.
EKG showed new LBB
Ashley Davidoff MD

EKG showed new LBB
Echo at the bedside in the ICU showed an ejection fraction of 15%, with global hypokinesis sparing the base of the heart. There was moderate MR, PAP 44-65mm Hg, RV was normal.
Preliminary diagnosis of an acute MI was made with acute systolic heart failure and cardiogenic shock

He was transferred to the Cath Lab
Prior to gaining access to the arterial system the patient went into PEA requiring sustained CPR requiring both epinephrine, atropine and urgent intubation
Emergent cardiac catheterization showed an LV pressure of 64/17 and wedge pressure of 41 mmHg. Temporary pacemaker was placed as well as an IABP. No significant CAD was identified.

AP PROJECTION
Which is the LAD? Look for the septal perforators running to the diaphragm

TAKOTSUBO CARDIOMYOPATHY LCA in A-P shows NO SIGNIFICANT STENOSES
Ashley Davidoff MD

LAD – Now there are some beautiful perforators off the LAD supplying 2/3 of the septum

TAKOTSUBO CARDIOMYOPATHY LCA in RAO shows NO SIGNIFICANT STENOSES
No significant CAD was identified. Ashley Davidoff MD

RCA – SA nodal of RCA (40%) Early Take of of the PDA , RCA Dominant (85%)

TAKOTSUBO CARDIOMYOPATHY RCA in LAO show NO SIGNIFICANT STENOSES
Ashley Davidoff MD

IABP placed

LV gram showed ballooning of the apex of the heart consistent with Takotsubo cardiomyopathy with an estimated ejection fraction of 10%

AKINETIC ANTERIOR WALL AND APEX – TAKOTSUBO

Serial CXR showed ongoing perihilar infiltrates with air bronchograms consistent with cardiogenic and alveolar edema.

Alveolar Edema – Air Bronchograms

ALVEOLAR EDEMA – CARDIOGENIC PULMONARY EDEMA 3 HRS LATER
TAKOTSUBO CARDIOMYOPATHY
Ashley Davidoff MD

He passed away 2 days later – Broken Hearted

Points of Interest
- Acute presentation and death from Takotsubo 1.8%
  Two hits personal physical ailment and emotional ailment of his wife’s admission to hospital

Review of Takatsubo Heart