Atypical stress cardiomyopathy associated with intraoperative catecholamine administration: A case report

Takotsubo syndrome (TTS), also known as stress cardiomyopathy, typically presents as apical ballooning in response to physical or emotional stress. However, atypical forms of stress cardiomyopathy can occur, such as mid-ventricular akinesis with apical sparing. Excessive catecholamine administration, particularly in a perioperative setting, is a known precipitant of this rare condition. We present a case of a 48-year-old Caucasian woman who developed atypical stress cardiomyopathy following the administration of high-dose catecholamines to treat intraoperative hypotension during an elective esophageal myotomy. The patient received multiple intravenous vasopressors, including epinephrine, norepinephrine, phenylephrine, and vasopressin, resulting in severe myocardial stress. Postoperatively, the patient experienced hemodynamic instability with ECG changes and troponin elevation suggestive of non-ST elevation myocardial infarction (NSTEMI). However, coronary angiography revealed no obstructive coronary artery disease, and transthoracic echocardiogram (TTE) demonstrated mid-ventricular akinesis with preserved apical function, consistent with atypical TTS. The patient was managed conservatively with beta-blockers and ACE inhibitors, leading to recovery of left ventricular function on repeat imaging. This case underscores the potential for high-dose catecholamines to induce atypical stress cardiomyopathy in the perioperative setting. Given the lack of obstructive coronary artery disease, the myocardial dysfunction was likely caused by catecholamine-induced myocardial stunning and excessive adrenergic stimulation. Recognition of this phenomenon is crucial for managing perioperative hypotension without exacerbating myocardial injury. Careful selection and titration of vasopressors may prevent the development of iatrogenic TTS in high-risk patients. • Atypical stress cardiomyopathy (CM) can present with mid-ventricular akinesis with apical sparing. • Excess catecholamine exposure can result in atypical stress CM. • Prompt recognition and management prevented permanent myocardial injury despite severe perioperative stress.