Heartbreak is on the menu: an unusual cause of cardiogenic shock

SESSION TITLE: Cardiovascular Disease Case Report Posters 19 SESSION TYPE: Case Report Posters PRESENTED ON: 10/10/2023 09:40 am - 10:25 am INTRODUCTION: Cardiogenic shock is a result of insufficient tissue perfusion due to inadequate contractility of the myocardium. We present an unfortunate case of asphyxiation leading to Takotsubo Cardiomyopathy (TTS) resulting in cardiogenic shock. CASE PRESENTATION: An 80-year-old female presented to the hospital after ingesting a turkey sandwich leading to mechanical asphyxiation. EKG showed ST-elevations in leads III, aVF, and V1 with initial troponin 114 ng/mL. She was intubated for respiratory distress but immediately suffered a cardiac arrest from a left-sided tension pneumothorax due to food impaction in the right bronchus. After two rounds of CPR and insertion of a chest tube, ROSC was achieved. Bronchoscopy showed partially chewed food in airways, that was retrieved. Echocardiogram showed decreased EF < 15%, with TTS vs left anterior descending artery territory ischemia. Coronary angiography showed no significant coronary artery disease. The patient required norepinephrine and milrinone infusions. She later developed atrial fibrillation and was started on amiodarone and therapeutic enoxaparin. The patient eventually was made comfort care due to poor prognosis. DISCUSSION: The major mechanism for TTS is the disproportion of catecholamine surge in response to stress. 10% of patients with TTS develop cardiogenic shock with a 10-fold increase in mortality. Some cardiogenic shock is caused by left ventricular outflow tract obstruction (LVOTO). Management of cardiogenic shock is dependent on the presence of LVOTO. Inotropic agents are contraindicated in patients with LVOTO as they can worsen the degree of obstruction due to the catecholamine properties. TTS with LVOTO should be treated similarly to hypertrophic cardiomyopathy. Beta-blockers are used to decrease the preload resulting in relief of the outflow obstruction. Due to hypotension, our patient could not tolerate this medication. Milrinone is a non-catecholamine inotrope and has been shown to have a lower incidence of induced tachycardia and myocardial oxygen consumption compared to catecholamine inotropes. Our patient developed hyperdynamic LVOTO as a result of milrinone-induced tachyarrhythmia. Caution should be used, as titrating off either milrinone or other inotropes causes a decrease in perfusion. The next step to consider when other therapies have failed is mechanical circulatory support. TTS is usually self-limiting with removal of the offending agent; however, when accompanied by cardiogenic shock, more studies should be obtained to determine the most optimal interventions. CONCLUSIONS: It is unusual to result in cardiogenic shock from choking on food. It is important to be mindful of severe complications of TTS so that early intervention can be initiated. REFERENCE #1: Vallabhajosyula, S., Barsness, G. W., Herrmann, J., Anavekar, N. S., Gulati, R., & Prasad, A. (2020). Comparison of complications and in-hospital mortality in takotsubo (apical ballooning/stress) cardiomyopathy versus acute myocardial infarction. The American Journal of Cardiology, 132, 29–35. https://doi.org/10.1016/j.amjcard.2020.07.015 REFERENCE #2: Yoshikawa, T. (2015). Takotsubo cardiomyopathy, a new concept of cardiomyopathy: Clinical features and pathophysiology. International Journal of Cardiology, 182, 297–303. https://doi.org/10.1016/j.ijcard.2014.12.116 REFERENCE #3: Mager, G., Klocke, R. K., Kux, A., Höpp, H.-W., & Hilger, H. H. (1991). Phosphodiesterase III inhibition or adrenoreceptor stimulation: Milrinone as an alternative to dobutamine in the treatment of severe heart failure. American Heart Journal, 121(6), 1974–1983. https://doi.org/10.1016/0002-8703(91)90834-5 DISCLOSURES: No relevant relationships by Anas Atrash No relevant relationships by Nathan Dincher No relevant relationships by Luis Meza No relevant relationships by WERN LYNN NG No relevant relationships by Benjamin Ravichander No relevant relationships by Lillian Sangha No disclosure on file for Michaela Sangillo No disclosure on file for Joanna Paula Sta Cruz