Case report: recurrent biventricular Takotsubo cardiomyopathy in a middle-aged man with fatal outcome after full recovery

BACKGROUND: Takotsubo cardiomyopathy (TC) usually manifests as transient apical ballooning of the left ventricle and may mimic acute coronary syndrome. Concomitant right ventricle involvement may occur in about a third of the cases. Recurrence had been observed in up to 10% of TC with variable ventricular involvement. Despite this knowledge, there had been no report of a patient with multiple biventricular TC in the literature to date. In this study, we describe a rare case of a patient who presented twice with biventricular TC. CASE SUMMARY: A 52-year-old man with a previous episode of biventricular TC 5 months ago presented to our hospital with a 1 day history of shortness of breath and wheeze. He was treated initially for infective exacerbation of chronic obstructive airway disease. He was eventually intubated following a trial of non-invasive ventilation. He became hypotensive post-intubation and required intensive care support. An inpatient echocardiogram revealed biventricular apical ballooning. Invasive coronary angiogram showed no coronary artery disease. A repeat echocardiogram 14 days post-admission demonstrated full recovery of both ventricles. These findings were consistent with a second biventricular TC. Two months later, he was found deceased in the community seemingly from an unrelated cause. DISCUSSION: This case describes a middle-aged gentleman who suffered recurrent biventricular TC with no consistent triggers and an unrelated fatal sequel. None of these features were typical, and to our best knowledge had not been reported before. We hypothesize that his recurrent chronic obstructive pulmonary disease exacerbations and various substance misuse might have predisposed him to this unusual presentation.