Takotsubo cardiomyopathy with acute pulmonary edema and mid-myocardial bridging of the lad: a case report

Takotsubo cardiomyopathy with acute pulmonary edema and mid-myocardial bridging of the lad: A case report

Shilpa S ^1*, Gowdham Pannirselvam²

¹Nursing Incharge, Kauvery Hospital, Marathahalli, Bengaluru

²Sr. Nurse Educator, Kauvery Hospital, Marathahalli, Bengaluru

*Correspondence

Abstract

Background
Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a transient form of left ventricular dysfunction that can closely resemble acute coronary syndrome. It is predominantly reported in women and may present with symptoms ranging from breathlessness and chest discomfort to acute heart failure and pulmonary edema.

Case Presentation

A 51-year-old female presented to the emergency department with shortness of breath and cough. On admission, she was tachycardic and tachypneic, with an oxygen saturation of 87% on room air. Her medical history included hypertension, type 2 diabetes mellitus, and previous stroke. Echocardiographic evaluation demonstrated moderate left ventricular systolic dysfunction with an ejection fraction of 30-35%. Coronary angiography was performed and demonstrated mid-myocardial bridging of the left anterior descending artery without significant obstructive coronary disease. The patient was managed with medical and supportive treatment. During hospitalization, QT prolongation was noted and electrolyte correction was performed. Her clinical condition improved with treatment, and she was discharged in a hemodynamically stable condition.

Conclusion
This case highlights the importance of recognizing Takotsubo cardiomyopathy in patients presenting with acute respiratory symptoms and left ventricular dysfunction. Understanding the normal anatomy and physiology of the heart helps in appreciating the changes occurring during stress-induced cardiomyopathy. Early cardiac evaluation, appropriate monitoring and supportive management are important for favorable outcomes.

Keywords: Takotsubo cardiomyopathy, Stress cardiomyopathy, Myocardial bridging, Left ventricular dysfunction, Acute pulmonary edema, LAD, QT prolongation.

Introduction

The heart is a muscular organ responsible for maintaining continuous circulation of blood throughout the body. The left ventricle plays a major role in systemic circulation by receiving oxygenated blood from the left atrium and pumping it into the aorta. Any significant impairment in left ventricular contraction can reduce cardiac output and may result in symptoms of heart failure.

Takotsubo cardiomyopathy is a temporary cardiac condition characterized by left ventricular systolic dysfunction that may occur following physical or emotional stress. The presentation can closely resemble acute coronary syndrome, making early assessment and differentiation important. Unlike a typical myocardial infarction caused by an obstructed coronary artery, Takotsubo cardiomyopathy usually occurs without a corresponding obstructive coronary lesion. The condition is believed to involve an excessive catecholamine response, resulting in myocardial stunning and temporary impairment of ventricular contraction.

The present case describes a 51-year-old female who presented with acute respiratory symptoms and was found to have moderate left ventricular dysfunction. Coronary angiography also demonstrated mid-myocardial bridging of the LAD. The case provides an opportunity to understand the relationship between normal cardiac anatomy and physiology and the changes that occur in Takotsubo cardiomyopathy.

Anatomy of the Heart Related to the Case

The heart consists of four chambers: the right and left atria and the right and left ventricles. The right side primarily handles deoxygenated blood, whereas the left side receives oxygenated blood from the lungs and pumps it into the systemic circulation.

Left atrium: The left atrium receives oxygenated blood from the pulmonary veins. During ventricular diastole, blood passes through the mitral valve into the left ventricle.

Left ventricle: The left ventricle is the main pumping chamber for systemic circulation. It has a relatively thick muscular wall because it must generate sufficient pressure to pump blood through the aorta and throughout the body. During diastole, the left ventricle relaxes and fills with blood. During systole, the ventricular muscle contracts and ejects blood through the aortic valve into the aorta. Therefore, effective left ventricular contraction is essential for maintaining adequate cardiac output and tissue perfusion.

Coronary arteries: The heart muscle itself requires a continuous supply of oxygen and nutrients. This is provided by the coronary arteries.

The major coronary arteries arise from the aortic root. The two main coronary arteries are:

Right coronary artery
Left coronary artery

The left coronary artery divides primarily into the:

Left anterior descending artery (LAD)
Left circumflex artery (LCx)

Left anterior descending artery

The LAD travels along the anterior interventricular groove and supplies important portions of the:

Anterior wall of the left ventricle
Interventricular septum
Apical region of the heart

Because of the extensive area supplied by the LAD, abnormalities involving this artery can significantly affect left ventricular function.

Myocardial Bridging – Anatomical Relevance

Normally, coronary arteries travel over the surface of the heart. In myocardial bridging, a segment of the coronary artery passes underneath a band of heart muscle.

The artery therefore has:

Normal anatomy: Coronary artery → runs on the surface of the myocardium

Myocardial bridging

Coronary artery → passes through the myocardium → re-emerges on the surface

The bridged segment can be compressed during ventricular contraction. In many individuals this remains clinically insignificant, but in some patients it may influence coronary blood flow, particularly during periods of increased cardiac demand.

Image Source: clinmedjournals; Myocardial Bridges a Forgotten Condition: A Review; Martín Ibarrola

In the present case, coronary angiography demonstrated mid-myocardial bridging of the LAD. Normal Cardiac Physiology: Under normal conditions, cardiac function depends on coordinated electrical activity, myocardial contraction, coronary perfusion and adequate ventricular filling.

The cardiac cycle consists mainly of:

Diastole: During diastole, the ventricles relax and fill with blood.

Systole: During systole, the ventricles contract and eject blood into the pulmonary artery and aorta. The amount of blood ejected by the left ventricle during each contraction is known as stroke volume.

Cardiac output can be represented as:

Cardiac Output = Heart Rate × Stroke Volume

Therefore, adequate cardiac output requires:

Appropriate heart rate
Adequate ventricular filling
Effective myocardial contraction
Unobstructed blood flow

The Ejection Fraction (EF) represents the percentage of blood ejected from the left ventricle during systole. In a healthy heart, ventricular contraction is coordinated and sufficient to maintain systemic circulation.

What Happens in Takotsubo Cardiomyopathy?

In Takotsubo cardiomyopathy, the normal process of ventricular contraction becomes temporarily impaired.

Takotsubo cardiomyopathy

Physical/emotional stress → excessive sympathetic/catecholamine response → myocardial stunning → impaired LV contraction → reduced ejection fraction

The exact mechanism is not completely understood. However, excessive catecholamine stimulation is considered an important factor.

High levels of circulating catecholamines can affect myocardial cells and coronary microvascular function. This can result in temporary myocardial stunning and regional or global impairment of ventricular contraction.

Importantly, this dysfunction can occur without significant obstructive coronary artery disease.

Normal vs Abnormal Pathophysiology

Normal physiology	Abnormal physiology in Takotsubo cardiomyopathy
Normal sympathetic response	Excessive sympathetic/catecholamine stimulation
Normal myocardial contraction	Temporary myocardial stunning
Coordinated LV contraction	Regional LV wall-motion abnormality
Normal LV systolic function	Reduced LV systolic function
Adequate cardiac output	Reduced effective cardiac output
Normal ventricular filling pressure	Increased filling pressures may occur
Normal pulmonary circulation	Increased pulmonary venous pressure may develop
Normal oxygenation	Pulmonary congestion can lead to hypoxemia
Normal electrical stability	QT prolongation and other ECG abnormalities may occur

Clinical Course

The patient was managed with medical and supportive treatment, including diuretics, antiplatelet therapy, anticoagulation, statin therapy and other cardiac medications according to her clinical requirements. Because of the acute presentation and ventricular dysfunction, she required close monitoring during the initial period of hospitalization. Her symptoms gradually improved with treatment. The patient was subsequently shifted to the ward and remained hemodynamically stable. She was discharged with advice regarding medication adherence, dietary modification, activity as tolerated and monitoring of blood pressure and blood glucose, with cardiology follow-up.

Discussion

This case demonstrates how Takotsubo cardiomyopathy can present predominantly with respiratory symptoms rather than classical chest pain. The patient’s initial presentation of breathlessness, tachypnea and hypoxemia was associated with significant LV systolic dysfunction. From a pathophysiological perspective, the reduction in ventricular contractility can result in increased left-sided filling pressures and pulmonary congestion, explaining the respiratory presentation. The echocardiographic finding of reduced EF was important in identifying the degree of ventricular dysfunction. Coronary angiography was subsequently useful in evaluating the coronary anatomy and did not demonstrate significant obstructive coronary disease. Instead, mid-myocardial bridging of the LAD was identified. The development of QT prolongation during the hospital stay was another clinically important finding. This emphasizes the need for continuous cardiac monitoring in patients with Takotsubo cardiomyopathy, particularly during the acute phase. The patient’s improvement with medical management and eventual hemodynamic stabilization is consistent with the potentially reversible nature of Takotsubo-related myocardial dysfunction.

Normal vs Abnormal – Overall Clinical Picture

Parameter	Normal	Findings in this case
LV contraction	Effective	Impaired
LV ejection fraction	Preserved	30–35%
Coronary anatomy	Arteries usually remain on myocardial surface	Mid-myocardial LAD bridging
Coronary obstruction	No significant obstruction	No significant obstructive lesion documented
Cardiac output	Adequate	Potentially reduced
Heart rate	Normal resting range	140/min
Respiratory rate	Normal	30/min
Oxygen saturation	Normal	87% on room air
Pulmonary circulation	Normal pressure	Pulmonary congestion associated with LV dysfunction
ECG repolarization	Normal QT interval	QTc approximately 516 ms
Myocardial function	Normal contraction	Temporary myocardial dysfunction
Clinical status	Stable	Acute cardiopulmonary presentation

Conclusion

Takotsubo cardiomyopathy is an important cause of acute left ventricular dysfunction and can present with features of acute heart failure. Understanding the normal anatomy and physiology of the left ventricle and coronary circulation helps in understanding the changes that occur during the disease process. In this patient, impaired LV systolic function with an EF of 30–35% was associated with significant respiratory symptoms and hypoxemia. Coronary angiography did not demonstrate significant obstructive coronary disease but identified mid-myocardial bridging of the LAD. QT prolongation during hospitalization further emphasized the need for continuous cardiac monitoring. This case highlights the importance of a systematic approach involving clinical assessment, echocardiography, coronary evaluation, ECG monitoring and supportive management in patients presenting with acute cardiopulmonary symptoms and ventricular dysfunction.

Learning points

Takotsubo cardiomyopathy can present primarily with acute breathlessness and features of heart failure.
Understanding normal LV anatomy and physiology helps explain the clinical manifestations of LV dysfunction.
A reduced EF reflects impaired ventricular systolic function and can contribute to pulmonary congestion and hypoxemia.
Myocardial bridging of the LAD is an anatomical finding that should be interpreted in the context of the patient’s overall clinical picture.
QT prolongation can occur during Takotsubo cardiomyopathy and warrants ECG monitoring and correction of electrolyte abnormalities.
Early recognition and appropriate supportive management can result in significant clinical improvement.

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Takotsubo cardiomyopathy with acute pulmonary edema and mid-myocardial bridging of the lad: a case report

Takotsubo cardiomyopathy with acute pulmonary edema and mid-myocardial bridging of the lad: A case report

Shilpa S 1*, Gowdham Pannirselvam2

Nightingale Journals

Shilpa S ^1*, Gowdham Pannirselvam²