Mitral Valve Transcatheter Edge-to-Edge Repair-Induced Takotsubo Cardiomyopathy

A 92-year-old woman underwent transthoracic echocardiography to investigate potential causes of her dyspnea. Her left ventricular ejection fraction (LVEF) was normal (67%), but degenerative severe mitral regurgitation (MR) with P2 prolapse was observed on color Doppler imaging (Figure A). Mitral valve transcatheter edge-to-edge repair (M-TEER) procedure was performed under general anesthesia and intraoperative hypotension was managed with norepinephrine infusion. The A2 and P2 leaflets were successfully grasped, reducing MR to mild or less (Figure B, 2D image; Figure C, 3D image). On postoperative day (POD) 1, laboratory test results indicated elevated cardiac enzymes, but no ECG changes or localized wall asynergy were observed; hence, we monitored the patient conservatively. By POD 3, her cardiac enzyme levels had declined, but ECG findings showed widespread T-wave inversion (Figure D). Follow-up echocardiography showed apical wall motion abnormalities and reduced LVEF (26%). Coronary computed tomography angiography revealed no significant stenosis (Figure E). By POD 7, the T-wave inversions were more pronounced, but improved spontaneously thereafter. She was diagnosed with M-TEER-induced Takotsubo cardiomyopathy. Postoperative nuclear imaging showed a mismatch between thallium and BMIPP uptake (Figure F), which recovered 2 months later (Figure G), supporting the diagnosis. She was successfully treated with temporary diuretic therapy, discharged without complications, and LVEF ultimately recovered.

Figure.

Multimodality imaging before and after mitral valve transcatheter edge-to-edge repair (M-TEER). (A) Pre-M-TEER and (B: 2D, C: 3D) post-M-TEER images obtained via transesophageal echocardiography. (D) ECG changes observed over time. (E) Coronary computed tomography angiography showing no significant stenosis. (F) Thallium (Tl) and BMIPP images demonstrate a mismatch. (G) Recovery observed at 2 months post-discharge. POD, postoperative day; RCA, right coronary artery; LAD, left anterior descending artery; LCX, left circumflex artery.

Potential mechanisms in this case include mechanical stress on the chordae tendineae and papillary muscles during leaflet grasping and hemodynamic changes from increased afterload post procedure. Additionally, catecholamine infusion, advanced age, and postoperative delirium may have led to significant physiological and psychological stress.

Takotsubo cardiomyopathy is triggered by physical or emotional stress, with catecholamines implicated in its pathogenesis.^1,2 This case illustrates the potential for Takotsubo cardiomyopathy following M-TEER, emphasizing the need for careful postoperative monitoring and the diagnostic value of non-invasive imaging.

COI / Funding

None.

References

• 1.   Lyon AR, Citro R, Schneider B, Morel O, Ghadri JR, Templin C, et al. Pathophysiology of Takotsubo syndrome: JACC state-of-the-art review. J Am Coll Cardiol 2021; 77: 902–921.
• 2.   Nishimura Y, Komatsu J, Sugane H, Hosoda H, Imai RI, Nakaoka Y, et al. Takotsubo syndrome in older men: Clinical characteristics differ by sex and age. Circ Rep 2024; 6: 201–208.