title: A Heartbreaking Renal Transplantation: Is Norepinephrine the Culprit to Blame?
abstract: BACKGROUND
  Takotsubo cardiomyopathy (TCM), also known as "broken heart syndrome," "apical ballooning syndrome," and "stress-induced cardiomyopathy," was first described in Japanese patients in 1990 by Sato et al. TCM is an increasingly recognized syndrome characterized by transient and reversible systolic dysfunction of the apical and middle segments of the left ventricle. This syndrome resembles acute myocardial infarction in the absence of evident coronary artery occlusion. Herein, we present a case of a 51-year-old male who underwent his second deceased-donor renal transplantation for end-stage-renal-disease due to a work-related accident. Perioperatively, initiation of continuous infusion of noradrenaline was decided to achieve adequate graft perfusion due to persistently low blood pressure. On the second postoperative day, the patient experienced tachycardia and atypical angina-like chest pain. Electrocardiogram (ECG) showed signs of myocardial infarction and elevated troponin levels were observed. Urgent coronary angiography was normal and transthoracic echocardiography (TEE) was indicative for Takotsubo cardiomyopathy.
  
  
  CONCLUSIONS
  Although, the precise pathophysiology of Takotsubo cardiomyopathy is still unknown, it seems that it is associated with excessive sympathetic stimulation, microvascular dysfunction, coronary artery vasospasm, and abnormal myocardial tissue metabolism. The development of patient's symptoms after the initiation of norepinephrine along with their immediate resolution after the discontinuation of the drug might suggest a causal relationship. This is the first time that TCM after renal transplantation is thought to be linked with the administration of exogenous catecholamines.
authors.affiliation: Transplantation Unit, Athens University School of Medicine, "Laiko" General Hospital, Athens, Greece. Electronic address: mike_vailas@yahoo.com.
authors.forename: M G
authors.initials: MG
authors.lastname: Vailas
authors.affiliation: Transplantation Unit, Athens University School of Medicine, "Laiko" General Hospital, Athens, Greece.
authors.forename: S
authors.initials: S
authors.lastname: Vernadakis
authors.affiliation: Transplantation Unit, Athens University School of Medicine, "Laiko" General Hospital, Athens, Greece.
authors.forename: K
authors.initials: K
authors.lastname: Kakavia
authors.affiliation: Department of Cardiology, Athens University School of Medicine, "Laiko" General Hospital, Athens, Greece.
authors.forename: I
authors.initials: I
authors.lastname: Paizis
authors.affiliation: Transplantation Unit, Athens University School of Medicine, "Laiko" General Hospital, Athens, Greece.
authors.forename: J
authors.initials: J
authors.lastname: Bokos
authors.affiliation: Nephrology Department, Athens University School of Medicine, "Laiko" General Hospital, Athens, Greece.
authors.forename: J
authors.initials: J
authors.lastname: Boletis
authors.affiliation: Transplantation Unit, Athens University School of Medicine, "Laiko" General Hospital, Athens, Greece.
authors.forename: G
authors.initials: G
authors.lastname: Zavos
mesh_terms: D002637:Chest Pain / Q000209:etiology; D017023:Coronary Angiography; D003937:Diagnosis, Differential; D004452:Echocardiography / Q000009:adverse effects; D004562:Electrocardiography; D006352:Heart Ventricles / Q000503:physiopathology; D006801:Humans; D016030:Kidney Transplantation / Q000009:adverse effects*; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000175:diagnosis; D009638:Norepinephrine / Q000009:adverse effects*; D011183:Postoperative Complications / Q000209:etiology; D012086:Reoperation; D054549:Takotsubo Cardiomyopathy / Q000139:chemically induced* / Q000175:diagnosis; D014336:Troponin / Q000378:metabolism; D014662:Vasoconstrictor Agents / Q000009:adverse effects*
chemical_list: D014336:Troponin; D014662:Vasoconstrictor Agents; D009638:Norepinephrine