Recurrent biventricular takotsubo cardiomyopathy with fatal outcome

A woman in her 60s presented initially with nausea, vomiting and abdominal pain. She rapidly progressed to respiratory failure requiring intubation. ECG demonstrated no significant ST segment changes. Troponin I and brain natriuretic peptide were elevated. Chest CT angiography demonstrated small non-occlusive segmental pulmonary emboli. Transthoracic echocardiogram findings suggested biventricular takotsubo cardiomyopathy (TCM) with left ventricular ejection fraction of less than 20%. She improved with aggressive management and was discharged on carvedilol, lisinopril, atorvastatin and apixaban. Follow-up echocardiogram revealed complete resolution of the left and right ventricular wall motion abnormalities at 9 weeks. She had symptoms recurrence after 7 months from the initial presentation. Repeated echocardiogram was consistent with biventricular TCM recurrence. Despite aggressive medical therapy, multiorgan failure developed and patient care was later transitioned to palliative care.