Takotsubo Cardiomyopathy and LV Outflow Tract Obstruction after Initiation of Novel Oral Chemotherapy.

BACKGROUND:Japanese authors first reported a reversible cardiomyopathy due to emotional stress known as Takotsubo cardiomyopathy or stress-induced cardiomyopathy or apical ballooning syndrome. In this case report, we describe Takotsubo cardiomyopathy associated with use of a chemotherapy drug, Regorafenib (Stivarga). CASE HISTORY:A 72-year-old female with history of metastatic colon cancer, with liver metastasis status post-resection and a recent diagnosis of primary non-small cell lung cancer on chemotherapy presented with shortness of breath exacerbated on exertion for 3 days. Patient was treated with Regorafenib for 10 days. EKG done showed 2mm ST elevation in V2-V4 leads and troponin was elevated to 6.8 ng/ml. The patient was taken for emergency cardiac catheterization which revealed normal coronaries but left ventriculogram showed low ejection fraction of 30% with apical akinesis and basal hyperkinesis with typical Takotsubo pattern. DISCUSSION:Regorafenib is a multi-kinase inhibitor, approved by the FDA for metastatic colon carcinoma, hepatic carcinoma and advanced gastrointestinal stromal tumors. The stress of cancer diagnosis and chemotherapeutic agents can cause significant cardiac mortality including Takotsubo cardiomyopathy. Cardiogenic shock and thromboembolic complications are an important cause of mortality. CONCLUSION:This is a rare presentation of Takotsubo cardiomyopathy associated with use of Regorafenib along with dynamic LVOT obstruction and systolic anterior motion of the mitral valve.