An unusual trigger for a neurogenic left ventricular dysfunction: Tako-Tsubo syndrome associated with hepatic encephalopathy.

摘要

To the Editor: A 54-year-old woman was admitted for icterus. She used to drink four glasses of alcohol daily. On admission, laboratory tests showed moderate liver dysfunction (pro-thrombin time 36%), mild hepatic cytolysis and icterus without cholestasis. Initial neurological exam and renal function were normal. Ultrasound revealed signs of portal hypertension and mild ascites. The patient was transferred to the hepatology department where the diagnosis of alcoholic cirrhosis was confirmed. The day after admission, she rapidly developed coma. She had no fever, and blood pressure was 125/75 mmHg, heart rate 110/min with no sign of tissue hypoperfusion. Her condition worsened rapidly, leading to intubation for airway protection. Eight hours after the onset of coma, she developed arterial hypotension. No evidence of sepsis was found. The 12-lead ECG recorded an ST segment elevation in leads V1-V3 associated with small Q-waves, suggesting acute coronary syndrome. Serum troponin was measured at 8.9 ng/ml and liver function was stable. Echocardiography revealed severe hypokinesia of the apical wall, while basal segments of the left ventricle were hyperkinetic. Left ventricular ejection fraction (LVEF) was 20%. She quickly needed introduction of intravenous epinephrine to maintain adequate mean arterial pressure. Coronary angiography was promptly performed. Only an insignificant stenosis of the right coronary was found. Left ventricular (LV) angiography was highly suggestive of Tako-Tsubo syndrome (Fig. 1).