Takotsubo syndrome triggered by perioperative and post-resuscitation stress: Case report

Takotsubo syndrome or "broken heart syndrome," is an uncommon but increasingly recognized condition that can mimic acute coronary syndrome and is characterized by transient regional left ventricular dysfunction, often with apical ballooning. Perioperative physiological stress, catecholamine surges, and vasopressor exposure are recognized triggers. This case describes suspected perioperative takotsubo syndrome in a high-risk surgical patient and emphasizes the need for vigilance and early recognition. A 66-year-old woman with hypertension, type B aortic dissection, prior stroke, carotid disease, hyperlipidemia, and tobacco use presented with a left intertrochanteric fracture requiring operative repair. During anesthesia induction, she developed profound hypotension and bradycardia refractory to fluids and vasopressors, resulting in procedure cancellation. Her initial echocardiogram demonstrated normal systolic function without regional wall motion abnormalities. Surgery was rescheduled the following day; however, she experienced pulseless electrical activity arrest postoperatively. Advanced cardiovascular life support with epinephrine achieved return of spontaneous circulation. A post-arrest echocardiogram demonstrated new mid-apical hypokinesis with an ejection fraction of 35%-40%, most consistent with takotsubo syndrome in the clinical context. She was treated with guideline-directed medical therapy, including beta-blockade and an ACE inhibitor, with subsequent stabilization and discharge. Formal coronary angiography was not performed, and the patient was lost to cardiology follow-up, limiting definitive exclusion of obstructive coronary artery disease and confirmation of left ventricular recovery. This case illustrates the multifactorial perioperative contributors to takotsubo syndrome and highlights the importance of recognizing warning features, including recurrent hypotension, catecholamine exposure, labile hemodynamics, and high-risk cardiovascular comorbidity.