title: Inverted-Takotsubo cardiomyopathy: severe refractory heart failure in poly-trauma patients saved by emergency extracorporeal life support.
abstract: OBJECTIVE
  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 µg/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.
authors.affiliation: Department of Cardiac Surgery, Experimental and Clinical Medicine, University of Florence, Florence, Italy massimo.bonacchi@unifi.it.
authors.forename: Massimo
authors.initials: M
authors.lastname: Bonacchi
authors.affiliation: Department of Cardiac Surgery, Experimental and Clinical Medicine, University of Florence, Florence, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Vannini
authors.affiliation: Department of Cardiac Surgery, Experimental and Clinical Medicine, University of Florence, Florence, Italy.
authors.forename: Guy
authors.initials: G
authors.lastname: Harmelin
authors.affiliation: Department of Anesthesia and Intensive Care Unit, Emergency, Careggi Teaching Hospital, Florence, Italy.
authors.forename: Stefano
authors.initials: S
authors.lastname: Batacchi
authors.affiliation: Department of Cardiac Surgery, Experimental and Clinical Medicine, University of Florence, Florence, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Bugetti
authors.affiliation: Department of Cardiac Surgery, Experimental and Clinical Medicine, University of Florence, Florence, Italy.
authors.forename: Guido
authors.initials: G
authors.lastname: Sani
authors.affiliation: Department of Anesthesia and Intensive Care Unit, Emergency, Careggi Teaching Hospital, Florence, Italy.
authors.forename: Adriano
authors.initials: A
authors.lastname: Peris
mesh_terms: D000328:Adult; D015199:Extracorporeal Membrane Oxygenation / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000453:epidemiology / Q000209:etiology* / Q000628:therapy; D006801:Humans; D015994:Incidence; D007362:Intensive Care Units; D007558:Italy; D008297:Male; D009104:Multiple Trauma / Q000150:complications* / Q000628:therapy; D012189:Retrospective Studies; D054549:Takotsubo Cardiomyopathy / Q000150:complications* / Q000453:epidemiology / Q000628:therapy
keywords: Cardiomyopathy; Circulatory assistance; Emergency; Heart failure; Myocardial recovery; Trauma