We report the first published case of transient left ventricular apical ballooning syndrome (Takotsubo cardiomyopathy) in the setting of orthotopic liver transplantation.
A 65-year-old female with end-stage liver disease secondary to nonalcoholic steatohepatitis with stage 2 hepatocellular carcinoma underwent successful total hepatectomy, portal vein thrombectomy, and orthotopic liver transplantation.
The patient's past medical history included chronic systemic hypertension without prior history of cardiac disease, diabetes, smoking, hyperlipidemia, or illicit drug use. Pretransplant dobutamine stress echocardiography demonstrated hyperdynamic left ventricular function (ejection fraction 74%) with normal left ventricular size. A double product (defined as maximal systolic blood pressure ฯซ heart rate) of 21,714 and heart rate of 91% of maximum predicted were achieved. There were no stress-induced wall motion abnormalities. Cardiac valves were normal. Estimated right ventricular systolic pressure was 36 mm Hg.
The intraoperative course was very unremarkable. The patient had an estimated blood loss of 500 mL and received one unit of platelets. The patient did not require pressors during the procedure and had no hemodynamic instability. Thromboelastogram during the procedure did not reveal any evidence of hypercoagulation state.
The posttransplantation course was uneventful until 4 hours after transplant when ST elevation was noted on the telemetry monitor. A 12-lead electrocardiogram demonstrated ST segment elevation consistent with an acute anterolateral myocardial infarction (Fig. 1A).