Takotsubo Cardiomyopathy Following Intravaginal Local Anesthetic with Epinephrine in a Patient Undergoing McIndoe Vaginoplasty: A Rare Perioperative Event

Aim and background: Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy, is a transient left ventricular dysfunction often triggered by emotional or physiological stress.While typically associated with major surgical procedures or catecholamine surges, its occurrence following local anesthetic with epinephrine infiltration under general anesthesia is rare.We report a case of TCM in a patient undergoing McIndoe vaginoplasty, highlighting a potential perioperative cardiovascular risk in gynecological reconstructive surgery.Case description: A 26-year-old female with Mayer-Rokitansky-Kster-Hauser syndrome was scheduled for McIndoe vaginoplasty under general anesthesia.Following induction and hemodynamic stabilization, intravaginal infiltration of lidocaine with epinephrine was performed just prior to the surgical incision.Within minutes, the patient developed sudden intraoperative hemodynamic instability, including hypotension, tachycardia, and ST-segment changes on electrocardiography (ECG).Troponin levels were elevated, prompting suspicion of an acute coronary event.However, coronary angiography ruled out obstructive coronary artery disease, and echocardiography revealed apical ballooning of the left ventricle, confirming TCM.The patient was managed with supportive therapy, including beta-blockers and vasopressor support as needed.She recovered uneventfully, with follow-up echocardiography at 6 weeks, showing complete resolution of cardiac dysfunction.Conclusion: Takotsubo cardiomyopathy can occur intraoperatively even under general anesthesia, potentially triggered by local anesthetic with epinephrine.Clinicians should maintain a high index of suspicion for TCM in cases of sudden intraoperative cardiovascular instability, particularly in procedures involving vasoconstrictor agents.Clinical significance: This case highlights the importance of perioperative cardiovascular monitoring and awareness of rare but serious complications associated with local anesthetic and epinephrine infiltration.Early recognition and prompt supportive management can prevent adverse outcomes, emphasizing the need for multidisciplinary vigilance in gynecological reconstructive surgery.