Three episodes of recurrent Takotsubo syndrome pre- and post-heart transplantation: a case report

Cardiac sympathetic hyperactivity may be implicated in the pathogenesis of Takotsubo syndrome (TTS). With complete denervation of a transplanted heart, the recipient heart is less susceptible to sympathetic hyperactivity. We report a rare case of recurrent TTS in a heart transplant recipient from a donor with TTS. Iodine-123 meta-iodobenzylguanidine (¹²³I-MIBG) scintigraphy results for evaluating sympathetic activity are presented.

A 46-year-old woman underwent heart transplantation for dilated phase of hypertrophic cardiomyopathy following recurrent cerebral haemorrhage complications after left ventricular assist device therapy 2 years prior. The donor heart exhibited a transient mildly reduced left ventricular ejection fraction suggestive of TTS. Four years post-transplantation, she was admitted with difficulty breathing, and echocardiography showed decreased biventricular apical wall motion. During her treatment course, wall motion improved spontaneously, and giant negative T waves were observed on electrocardiography (ECG). Coronary computed tomography and endomyocardial biopsy findings were normal, and a diagnosis of TTS was made. Approximately 5 years post-transplantation, she was readmitted with difficulty breathing, and echocardiography showed akinesis of the mid-to-apical biventricular wall. Wall motion normalized within a few days, and ECG showed typical giant negative T waves, consistent with TTS. ¹²³I-MIBG scintigraphy taken prior to discharge and 6 months later showed minimal myocardial uptake in the basal anterior wall, indicating insufficient sympathetic reinnervation.

Recurrent TTS in a denervated heart suggests the possibility of other underlying mechanisms besides cardiac sympathetic hyperactivity. This case highlights potential TTS development in transplant recipients from donors with TTS, underlining the need for close monitoring.