Left ventricular plasty improved cardiac function in a case of takotsubo cardiomyopathy with persistent aneurysm

A 72-year-old woman was admitted to a local hospital due to repeated chest pain in December 2011. On admission, blood tests showed elevation of cardiac enzyme and B-type natriuretic peptide levels. Electrocardiography showed ST-segment elevation in almost all leads. Echocardiography showed akinesis in left ventricular (LV) apex, and hyperkinesis in basal LV. Urgent cardiac catheterization was performed. Coronary angiography showed no significant organic stenosis and the acetylcholine provocation test did not evoke coronary spasm. The left ventriculography revealed marked akinesis of the apical ballooning with hyperkinesis of the basal LV segments, suggesting takotsubo cardiomyopathy. Following the diagnosis, she started treatment for LV dysfunction with standard pharmacotherapy including beta blocker, aldosterone receptor blocker, and angiotensin-converting enzyme inhibitor. Even after 3 months, echocardiography demonstrated that LV wall motion was not recovered, and her symptoms of heart failure were not improved. Based on these findings, we considered that surgical LV plasty was necessary for the treatment of cardiac dysfunction in this patient. She underwent surgical operation (aneurysma resection and LV volume reduction) in April 2011. Pathological examination of the excised myocardial tissue from the aneurysm revealed damaged cardiomyocytes replaced with interstitial fibrosis and adipose tissue. After surgery, her LV systolic function and clinical symptoms dramatically improved. <Learning objective: Generally, patients with takotsubo cardiomyopathy have a favorable prognosis because the wall motion abnormality returns to normal without severe complications. There are only a few cases where surgical interventions were applied for takotsubo cardiomyopathy. This is an interesting case suffered from persistent severe heart failure and underwent surgical LV plasty for the LV aneurysm. After surgery, her LV systolic function and clinical symptoms dramatically improved. Pathological findings of the resected LV tissue showed that fibrosis and adipose tissue replaced myocardial fibers.>.