Association of inverted Takotsubo cardiomyopathy with postpartum pneumo-mediastinum: when a “broken lung” meets a “broken heart”

Excerpt

Six hours after an uneventful delivery, a 30-year-old primiparous woman complained of pleuritic-type chest pain and sense of immense apprehension. Initially, Troponin-I (Tn-I) level was normal (0.01 ng/mL), but D-dimer was elevated (1200 µg/L). Pulmonary embolism was excluded by a computed tomography scan, which revealed signs of pneumo-mediastinum and subcutaneous emphysema (a). Shortly after, due to raised Tn-I level to 1.88 ng/mL and T-wave inversion in anterior precordial leads, she was referred to us. Angiography disclosed normal coronary arteries (b, c), but wall-motion abnormalities (WMA) in basal segments were noted (d). Cardiac magnetic resonance imaging excluded late gadolinium enhancement (e, f). Transthoracic echocardiography showed significant hypo- to akinesis of basal inferior and posterior left ventricular wall and dyskinesis of basal anteroseptal segments (g, h). Estimated ejection fraction (EF) by 3D quantification was 27 % (i, j). This peculiar pattern of WMA with clinical settings and normal coronary arteries was consistent with reversed/inverted Takotsubo cardiomyopathy (ITC). She received appropriate management with beta-blockers and angiotensin-converting enzyme inhibitors. EF was completely normalized after 1 month (k, l). To the best of our knowledge, this association of pneumo-mediastinum and ITC has not been reported. Notably, ITC occurs more frequently in younger age and is more commonly associated with mental stress than the typical forms of Takotsubo cardiomyopathy. …