Poster 059: Catecholamine-Induced Takotsubo Syndrome Complicated by Refractory Cardiogenic Shock Requiring VA-ECMO

Background: Takotsubo syndrome may be triggered by severe physical stress and exogenous catecholamine exposure and, in rare cases, can progress to refractory cardiogenic shock requiring advanced mechanical circulatory support

Methods: We report the case of a 23-year-old woman who developed cardiogenic shock following an elective orthopedic procedure under regional anesthesia. Management included stepwise hemodynamic support with vasopressors, inotropes, serial echocardiography, point-of-care ultrasound (POCUS), and venoarterial extracorporeal membrane oxygenation (VA-ECMO).

Outcome: A previously healthy 23-year-old woman developed severe bradycardia and profound hypotension (mean arterial pressure 35 mmHg) during elective orthopedic surgery. Initial management included atropine and epinephrine administration, after which she rapidly evolved to mixed distributive and cardiogenic shock, requiring invasive mechanical ventilation and high-dose vasopressor support with norepinephrine and vasopressin. Refractory vasoplegia was identified and successfully treated with methylene blue.
POCUS revealed reduced cardiac output with segmental left ventricular hypokinesia. Transthoracic echocardiography confirmed severe left ventricular systolic dysfunction with a left ventricular ejection fraction (LVEF) of 15%, consistent with Takotsubo syndrome. Inotropic support with dobutamine and levosimendan was initiated; however, due to persistent hemodynamic instability, VA-ECMO was instituted.
During five days of VA-ECMO support, progressive myocardial recovery was observed. LVEF improved to 20% after the first levosimendan infusion and to 33% following a second dose, allowing successful ECMO weaning. Complications included ECMO-related hemolysis requiring transfusion of packed red blood cells and platelets, rhabdomyolysis with creatine phosphokinase levels exceeding 1,200 IU/L, and signs of lower limb ischemia due to tibial artery compromise, which prompted expedited ECMO decannulation. The patient subsequently achieved full respiratory, renal, and neurological recovery, with successful liberation from mechanical ventilation.

Conclusion: Catecholamine-induced Takotsubo syndrome may rapidly progress to refractory cardiogenic shock, even in young patients. Early diagnosis, hemodynamic-guided therapy, and timely VA-ECMO initiation as a bridge to myocardial recovery are critical in reversible shock states and underscore the need for cautious catecholamine use.