Inverted-Takotsubo cardiomyopathy: severe refractory heart failure in poly-trauma patients saved by emergency extracorporeal life support

OBJECTIVES: The sequelae of severe poly-trauma may include myocardial dysfunction followed by acute heart failure and death. Inverted-Takotsubo cardiomyopathy (ITC) is a variant of stress cardiomyopathy, characterized by a contractile abnormality with extensive left ventricular circumferential dyskinesia or akinesia with a hyperkinetic apex. We report our experience with refractory cardiogenic shock and/or cardiac arrest, treated with extracorporeal life support. METHODS: From June 2008 to December 2011, we treated 4 adult poly-trauma patients (3 men, 1 woman, mean age: 27.7 +/- 13.5 years, mean ISS score 53.2 +/- 15.9) with veno-arterial (V-A) extracorporeal life support for cardiopulmonary failure/cardiac arrest refractory to conventional treatment, due to inverted-Takotsubo cardiomyopathy. We used a miniaturized extracorporeal life support (ECLS) device. RESULTS: ITC myocardial dysfunction appeared 15.4 +/- 11.6 h after intensive care unit admission and rapidly evolved to refractory cardiopulmonary failure and cardiac arrest (within 4.8 +/- 2.5 h of the onset). At ECLS, initiation median pH was 7.12 +/- 0.14 (6.91-7.25), median lactate was 6.7 +/- 2.8 (4-10) mmol/l and median vasoactive-inotropic score was 192.1 +/- 50.6 mu g/kg/min. Tissue perfusion improved significantly within 4 h on ECLS. Cardiac function improved gradually but consistently. Initial median ejection fraction was 14.2 +/- 4.7% and median global longitudinal strain test was -7.4 +/- 4.7. At complete cardiac recovery, they were 62.73 +/- 7.8 and -18.43 +/- 2.4%, respectively. After that, 2 patients survived and were sent to neurological rehabilitation before hospital discharge. In the other 2 cases, post-traumatic cerebral death occurred and they underwent organ explantation. CONCLUSIONS: Rapid heparin-free ECLS may improve outcome in the most severe cases of poly-traumatized patients demonstrating refractory inverted-Takotsubo cardiomyopathy.