CONGRESS ABSTRACT

68 years old female, smoker, with history of anxious depression in treatment with paroxetine. She presented to the emergency department with the complaint of fatigue and exertional dyspnea for the last week. Heart rate was 50 bpm, blood pressure 120/80 mmHg and oxygen saturation 99% on room air. ECG showed second degree atrioventricular (AV) block type 1 at a heart rate of 50 bpm and normal ventricular repolarization. Echocardiogram showed left ventricle with normal dimensions and ejection fraction (EF 65%), mild mitral and tricuspid regurgitation. Laboratory tests were normal. Telemetry monitoring was started, which showed periods of 2:1 AV block and advanced AV block, with a heart rate of 30 bpm. Infusional therapy with isoprenaline (1 ug/min) was started. Then, two hours later, permanent bicameral pacemaker was implanted, with locoregional anesthesia using lidocaine 2%. The procedure ended without complications. The following day, a routine echocardiogram was performed, and showed ejection fraction 40% with apical akinesia. ECG showed ventricular paced rhythm, negative T waves in V3-V6 and in the inferior leads, QTc 492 msec. Chest X-ray and pacemaker interrogation were performed and showed no anomalies. Laboratory test showed LDL 211 mg/dl, BNP 306 pg/mL (normal value<100 pg/ml) and troponin elevation with a peak of 187 pg/mL (normal value<16 pg/ml). Patient was totally asymptomatic, and she didn’t complaint of chest pain or dyspnea. A coronary angiography was performed, which showed a non hemodynamically significant stenosis of the left circumflex coronary artery and a microvascular disfunction (FFR 0.8, CFR 2.4, IMR 36). At this point a diagnosis of Tako Tsubo was made, and therapy with Cardioaspirin, Atorvastatin and Ramipril was started. The next day an echocardiogram was repeated, and showed the persistence of left ventricular disfunction with apical akinesia and the presence of an apical thrombus (13×8 mm). Aspirin was stopped and infusional therapy with unfractioned heparin was started (12 UI/kg/h). Two days later, the echocardiogram showed recovery of the left ventricular ejection fraction (EF 55%) and the motion of the apex, with disappearance of the thrombus. She was subsequently discharged on Edoxaban 60 mg/die. One month later an echocardiogram was repeated during an outpatient visit, and showed complete recovery of the ejection fraction (EF 65%) and absence of thrombus. For this reason Edoxaban was stopped and switched to Cardioaspirin.