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CASE REPORT
Year : 2022 | Volume
: 32
| Issue : 3 | Page : 177-179
Echocardiographic evolution of posterolateral left ventricular aneurysm with normal coronary arteries in patient recently COVID-19 vaccinated: A complicated atypical case of takotsubo syndrome vaccine-related?
Fabrizio Ceresa1, Antonio Micari2, Maria Paola TrifirÃ3, Francesco Costa2, Giampiero Vizzari2, Alessio Vite Giuseppe2, Francesco Patanè1
1 Department of Thoracic and Cardiovascular Surgery, Papardo Hospital, Messina, Italy
2 Division of Cardiology, G. Martino University Hospital, Messina, Italy
3 Department of Cardiology, Papardo Hospital, Messina, Italy
Correspondence Address:
Fabrizio Ceresa
Department of Thoracic and Cardiovascular Surgery, Papardo Hospital, Messina
Italy
Source of Support: None, Conflict of Interest: None
CheckDOI: 10.4103/jcecho.jcecho_27_22
A 72-year-old woman, recently COVID-19 vaccinated with a third dose, was referred to our center for acute chest pain and dyspnea. On admission, the electrocardiography showed a STEMI on inferior derivations and the dyskinesia of the inferior wall was found at the first transthoracic echocardiogram. The coronary angiography did not show coronary artery disease. After 1 week, a huge posterolateral left ventricular (LV) aneurysm with initial signs of rupture was found and the patient underwent a Dor's procedure to exclude the LV aneurysm. As far as we know, this is the first reported case of Takotsubo following the COVID-19 vaccination requiring cardiac surgery.
Keywords: COVID-19 vaccination, left ventricular aneurysm, myocardial infarction with nonobstructive coronary artery, Takotsubo Syndrome
Left ventricular aneurysm is usually one of the most serious complications of myocardial infarction. Takotsubo Sindrome (TTS) is defined as a transient systolic dysfunction with diffuse wall motion abnormalities, without coronary artery disease. The incidence of TTS has been increasing since the start of COVID-19 pandemic.
Case ReportA 72-year-old woman was referred to our center for acute chest pain and dyspnea. At hospital admission, the electrocardiography (ECG) showed a STEMI on the inferior derivations. The high-sensitivity troponin (peak 5789 ng/L) and natriuretic peptide (peak 881 pg/mL) were just moderately elevated, while the levels of other cardiac biomarkers were normal. She immediately underwent coronary angiography that showed normal coronary arteries [Figure 1]. Her past medical history revealed diabetes, obesity, and chronic obstructive pulmonary disease. She was vaccinated with the third dose of COVID-19 mRNA BNT162b2 about 2 weeks before. On admission, the molecular swab for research of SARS-CoV-2 was negative.
The level of troponin quickly went back to normal while ECG showed an evolution of the inferior myocardial infarction. The first transthoracic echocardiography showed a normal left ventricular (LV) diameter with hypokinesia of the inferior wall and a mild depression of the LV ejection fraction (EF 50%); mild pericardial effusion and mitral valve regurgitations were also found.
After 1 week, she kept suffering from exertional dyspnea. We performed second transthoracic echocardiography that showed a huge and weakened posterolateral LV aneurysm with a moderate depression of LV EF and an increasing of pericardial effusion. The SonoVue-enhanced echocardiography excluded the presence of thrombotic material into the aneurysm [Figure 2].
Figure 2: (a) Off-axis five-chamber view in transthoracic echocardiography allowed to found a postero-lateral left ventricular aneurysm with mild pericardial effusion (*). (b) The postero-lateral left ventricular aneurysm and the pericardial effusion (*) grew in size. (c) A further weakening of aneurismatic wall and an increase of the pericardial effusion are seen. (d) The SonoVue enhanced echocardiography excluded the presence of thrombotic material into the aneurysmThe first diagnostic hypothesis was atypical Takotsubo syndrome (TTS) type even if it was not confirmed by the cardiac magnetic resonance (CMR). Indeed, the patient categorically refused to perform a CMR because she suffered from claustrophobia.
Therefore, we have decided to follow with serial transthoracic echocardiography, the evolution of the aneurysm for 2 weeks.
After seeing the further weakening of the aneurismatic wall and increased of the pericardial effusion, the patient underwent a Dor's procedure to exclude the LV aneurysm. After performing longitudinal median sternotomy and opening the pericardium, the aneurysm was found in the mid-apical portion posterolateral LV wall [Figure 3]. The wall of the aneurysm was very thin, but there were no signs of rupture.
Figure 3: (a) The posterolateral left ventricular aneurysm was opened finding a very thin wall. (b) The Dor's procedure was performed to exclude the left ventricular aneurysm. (c) The wall of the left ventricular aneurysm was closed through a matress suture between two strings of DacronThe postoperative course was uneventful, and she was discharged home 10 days after the operation. After 6 months, she has done well.
DiscussionsLV aneurysm is usually one of the most serious complications of myocardial infarction and its incidence can achieve up to 10% of all of them.[1] The prevalence of myocardial infarction with nonobstructive coronary artery disease (MINOCA) ranges from 1% to 12% of all myocardial infarctions.[2]
Since the first case of TTS was described in Japan, it has been recognized in about of 2% of all acute coronary syndrome and heart failure defined as a transient regional wall motion abnormalities of left or right ventricular myocardium which are frequently but not always associated with emotional stress or sorrow.[3],[4]
The exact mechanism of this syndrome remains still unclear even if several hypotheses involving both vascular mechanisms and abnormal functioning of the autonomic and central nervous system have been done.
CMR is the first-line diagnostic tool for the assessment of TTS.
Indeed, the myocardial inflammation in the acute phase and the lack of late gadolinium enhancement of the dyskinetic area at CMR are two important hallmarks of TTS, which allow a diagnosis of certainty.[5]
During the COVID-19 pandemic, the incidence of TTS has increased from 1.5% to 7.8% and it probably depends on the similar mechanistic pathway involving the catecholamine's surges, which seems to play an important role in both syndromes.[6],[7]
Unfortunately, in our case, the lack of CMR does not allow us to rule out the LV aneurysm as a very rare complication of a MINOCA, even if atypical TTS related to COVID-19 vaccination seems to be the most likely hypothesis.
Indeed, the clinical presentation of this case suggests that the vaccination played an important role to develop the atypical TTS despite occurring only 2 weeks after the vaccine administration.
Nowadays, it has been only described six cases of TTS after the COVID-19 vaccination which have occurred after the first or the second dose but never after the third one and usually within 1 week.
So far it has been difficult to establish if the TTS was caused by the vaccine or the stress response.
In our opinion, this case is interesting for the following reasons.
First, the time from the vaccination to the onset of cardiac symptoms is longer than the other described cases and it could suggest that TTS postvaccine is caused by an abnormal delayed inflammatory reaction leading to a catecholamine surge.
Second, we were able to follow the evolution from the hypokinesia to the aneurysm of the posterolateral left ventricular wall and the further appearance of the signs of its impending rupture.
Third, to the best of our knowledge, this is the first case of TTS vaccine-related need undergoing cardiac operation for the risk of an upcoming rupture of the aneurysm.
In conclusion, our aim is only describing an atypical case of TTS after vaccination, but we strongly endorse the immunization drive against the SARS-CoV-2 virus.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient (s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
References
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