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Stuck in the upside down tackotsubo cardiomyopathy: A case of inverted tackotsubo cardiomyopathy during exploratory thoracotomy.

Abeer M Shawky

Background: Takotsubo cardiomyopathy is characterized by relatively benign transient systolic dysfunction of the apical segments of the left ventricle. Inverted (Upside down) Takotsubo cardiomyopathy (ITC) is a rare variant of TC. ITC is characterized by reversible regional wall motion abnormalities in the basilar segment of the left ventricle. Although it shares some pathogenic mechanisms with its more common variant, TC, differences exist in terms of echocardiographic features, demographics, clinical manifestations, laboratory features and prognosis. Here we pre-sent a case of intra-operative ITC. Case Summary: We report a case of ITC in a 44-year-old man who presented for an elective biopsy from mediastinal mass and suffered a peri-procedural cardiac arrest. He came to the hos-pital with dyspnea on exertion that had lasted for a few months but became exacerbated in the last three weeks. In the operating room; after uncomplicated induction of anaesthesia before the surgery, the patient went into pulseless electrical activity. The patient was resuscitated and maintained on supportive therapy. He was taken urgently for cardiac catheterization, which showed normal coronary arteries with akinetic basal and inferior walls and hyperkinesis of the apex. His ejection fraction decreased to 30% from 70% at baseline. He was placed on an appropriate heart failure regimen. An echocardiogram after two weeks showed complete resolution of cardiac dysfunction with symptoms improvement. With this normal coronary angiogram and transient systolic dysfunction of the mid and basal segments of the left ventricle; he was diagnosed with inverted (Upside down) TC. Conclusion: We offer this case as a reminder that stress during the surgical procedure should be considered one of the differential diagnosis of aetiology in patients presenting with TC. With supportive care and initiating treatment in a timely fashion, the long-term prognosis will be good in the vast majority of patients.