A Heartbreaking Renal Transplantation: Is Norepinephrine the Culprit to Blame?

Takotsubo cardiomyopathy (TCM), also known as "broken heart syndrome," "apical ballooning syndrome," and "stress-induced cardiomyopathy," was first described in Japanese patients in 1990 by Sato et al. TCM is an increasingly recognized syndrome characterized by transient and reversible systolic dysfunction of the apical and middle segments of the left ventricle. This syndrome resembles acute myocardial infarction in the absence of evident coronary artery occlusion. Herein, we present a case of a 51-year-old male who underwent his second deceased-donor renal transplantation for end-stage-renal-disease due to a work-related accident. Perioperatively, initiation of continuous infusion of noradrenaline was decided to achieve adequate graft perfusion due to persistently low blood pressure. On the second postoperative day, the patient experienced tachycardia and atypical angina-like chest pain. Electrocardiogram (ECG) showed signs of myocardial infarction and elevated troponin levels were observed. Urgent coronary angiography was normal and transthoracic echocardiography (TEE) was indicative for Takotsubo cardiomyopathy.

Although, the precise pathophysiology of Takotsubo cardiomyopathy is still unknown, it seems that it is associated with excessive sympathetic stimulation, microvascular dysfunction, coronary artery vasospasm, and abnormal myocardial tissue metabolism. The development of patient's symptoms after the initiation of norepinephrine along with their immediate resolution after the discontinuation of the drug might suggest a causal relationship. This is the first time that TCM after renal transplantation is thought to be linked with the administration of exogenous catecholamines.