UNIQUE CASE OF A TAKO-TSUBO CARDIOMYOPATHY OCCURRING IN A PATIENT WITH HEPATIC CIRRHOSIS SUBJECTED TO EVL

Aims:

Variceal bleeding is a lethal complication of liver cirrhosis. Endoscopic variceal ligation is recommended as the first-choice intervention for esophageal variceal bleeding in cirrhotic patients. Vasoactive drugs play a role in controll variceal bleeding by reducing portal blood flow and portal pressure. Terlipressin is a synthetic analogue of natural hormone vasopressin with relatively low incidence of adverse effects.

Methods:

A 80-year-old woman presented to the our Department of Gastroenterology with hematemesis. The patient was known to have been diagnosed with oesophageal varices F2, portal hypertension and liver cirrhosis (Child-Pugh A) most probably of dismetabolic etiology. Bleeding was stopped by ligation rings deployment and terlipressin therapy was started. The patient was discharged after ten days. Two months later, this patient was hospitalized for anemia and endoscopic drainage of varices at high risk of hemorrhagic relapse. It was performed EVL and the patient was treated with terlipressin under the same schedule as in the first case but in second day complained of chest pain and dyspnea. Serial EKGs did not show features compatible with acute coronary syndrome. Conversely, a trans-thoracic echocardiography disclosed akinesia of mid-apical segments with sistolic ballooning of the left ventricular apex, hyperkinetic motion of the basal segments, and marked reduction of LVEF (30%), suggesting the classic form of TTC. The infusion of terlipressin was immediately stopped. After terlipressin withdrawal, chest pain and dyspnea quickly resolved. A second transthoracic echocardiography, performed 1 day later, demonstrated the resolution of the mid-apical segments akinesia and normalization of LVEF (70%).

Results:

We describe a case of a cirrhotic patient with active variceal bleeding treated during two separate hospitalizations with terlipressin. In second drug treatment periods, developed a Tako-Tsubo cardiomyopathy, also known as transient left ventricular apical ballooning syndrome.

Conclusions:

This is a unique case of a TTC occurring in a patient with hepatic cirrhosis subjected to EVL.