Mechanical circulatory support for refractory cardiogenic shock in Takotsubo syndrome: a case report and review of the literature

Takotsubo syndrome (TTS) complicated by refractory cardiogenic shock is a challenging clinical problem, as treatment with inotropic agents and/or vasopressors is contraindicated. We illustrate this by a patient presenting with chest pain and shortness of breath caused by TTS complicated by cardiogenic shock requiring mechanical circulatory support (MCS). The patient received central extracorporeal life support with a cannula in the left atrium (pre-load reduction of left ventricle) and the return cannula in the ascending aorta (neutral on afterload). Treatment with MCS was complicated by a cardiac tamponade. Left ventricular function recovered after 24 h, and the patient was doing well at the outpatient clinic 7 weeks after discharge. In addition, we reviewed the literature (PubMed search) reporting on MCS in patients with TTS. Including our patient, 17 cases of TTS induced cardiogenic shock receiving MCS have been reported. Age of the patients ranged from 16 years to 74 years, and 71% of the patients were female. Extracorporeal life support was the most used type of MCS (82% of the cases). Two patients died, and complications of MCS were rare (one case of leg ischaemia). Theoretically, MCS devices that reduce pre-load and are neutral on afterload are preferable. However, no specific type of MCS can be recommended as randomized trials are lacking. In conclusion, our case and the available literature suggests that MCS in TTS induced refractory cardiogenic shock is an immediate and feasible lifesaving treatment.