Preoperative takotsubo cardiomyopathy in an octogenarian with severe mitral stenosis: Addressing diagnostic and therapeutic challenges

Abstract Background Takotsubo cardiomyopathy (TCM) is an acute cardiac syndrome characterized by transient left ventricular systolic dysfunction in the absence of obstructive coronary artery disease. It predominantly affects elderly women and is often triggered by physical or emotional stress. The occurrence of TCM complicated by cardiogenic shock in the preoperative setting poses significant diagnostic and therapeutic challenges. Case Illustration An 80-year-old woman with severe mitral stenosis and chronic atrial fibrillation was hospitalized for planned percutaneous mitral balloon valvuloplasty (PMBV). However, the procedure was abandoned after detection of a mobile fresh thrombus at the left atrial appendage, and urgent surgical mitral valve replacement (MVR) was scheduled. One day prior to the planned surgery, she developed sudden nausea, vomiting, bradycardia, and hypotension, progressing to cardiogenic shock accompanied by severe metabolic acidosis and hyperkalemia. The initial clinical impression attributed her deterioration to a combination of bronchopneumonia and azotemia. At intensive cardiac care unit (ICCU) admission, electrocardiography demonstrated dynamic ST–T changes. Echocardiography revealed newly reduced left ventricular ejection 29 % fraction with apical ballooning. High-sensitivity troponin levels showed only moderate elevation despite a large area of akinesia. Coronary angiography confirmed the absence of obstructive coronary artery disease, supporting the diagnosis of Takotsubo cardiomyopathy. The patient was managed with pharmacological hemodynamic support and continuous renal replacement therapy (CRRT). Surgical mitral valve replacement was successfully performed once left ventricular ejection fraction improved to 53%. Conclusion In the preoperative setting, TCM may significantly impact surgical timing and management strategy. Early recognition and multidisciplinary approach is essential to optimize outcomes.Figure 1.Transthoracic echocardiography demonstrating apical ballooning with basal hyperkinesis, consistent with Takotsubo cardiomyopathy (systolic and diastolic phases).