Spina Roberto, Song Ning, Kathir Krishna, Muller David W M, Baron David
Department of Interventional Cardiology, St Vincent's Hospital, Sydney, Australia.
Eur Heart J Case Rep. 2018 Apr 18;2(2):yty043. doi: 10.1093/ehjcr/yty043. eCollection 2018 Jun.
Stress cardiomyopathy, also known as takotsubo syndrome, is characterized by transient left ventricular dysfunction not attributable to obstructive epicardial coronary artery disease. Several pathological mechanisms have been proposed, including multivessel coronary artery vasospasm, coronary microcirculatory dysfunction, and excess catecholamine secretion.
A 68-year-old male presented to our institution for elective surgical removal of a cutaneous basal cell carcinoma on the right side of his face. Within minutes following the administration of local anaesthesia, the patient developed severe hypertension, tachycardia, ST-segment elevation on the electrocardiogram, and non-sustained broad-complex tachycardia. Urgent cardiac catheterization revealed non-obstructive coronary artery disease and left ventriculography demonstrated apical hypokinesia and moderate systolic dysfunction consistent with the takotsubo syndrome. On review of the medications administered, it was noted that an unintentionally large dose of adrenaline (4mg) had been injected subcutaneously with lignocaine. He was monitored in the coronary care and recovered fully with supportive care only. Bisoprolol was initiated on day 1 post procedure. On follow-up one month later, his left ventricular function had normalized.
Our case report provides direct evidence supporting the pathogenetic role of excess catecholamine secretion in the development of the takotsubo syndrome. A review of the literature reveals that both exogenous catecholamine administration (adrenaline injection in the context of anaphylaxis or infiltrative anaesthesia) and excess endogenous catecholamine (phaechromocytoma) secretion has been associated with the takotsubo syndrome. Local infiltrative anaesthesia with the addition of adrenaline is commonly used as a vasoconstrictor in a wide variety of surgical procedures. To reduce the risk of adverse events, the lowest effective concentration of adrenaline to provide pain control and vasoconstriction is recommended.
应激性心肌病，也称为Takotsubo综合征，其特征是短暂性左心室功能障碍，并非由阻塞性心外膜冠状动脉疾病引起。已经提出了几种病理机制，包括多支冠状动脉血管痉挛、冠状动脉微循环功能障碍和儿茶酚胺分泌过多。
一名68岁男性因择期手术切除面部右侧皮肤基底细胞癌前来我院就诊。在给予局部麻醉后几分钟内，患者出现严重高血压、心动过速、心电图ST段抬高以及非持续性宽QRS波心动过速。紧急心脏导管检查显示非阻塞性冠状动脉疾病，左心室造影显示心尖运动减弱和中度收缩功能障碍，符合Takotsubo综合征。在审查所使用的药物时，发现无意中皮下注射了大剂量肾上腺素（4mg）与利多卡因混合。他在冠心病监护病房接受监测，仅通过支持治疗就完全康复。术后第1天开始使用比索洛尔。一个月后的随访中，他的左心室功能已恢复正常。
我们的病例报告提供了直接证据，支持儿茶酚胺分泌过多在Takotsubo综合征发病机制中的作用。文献综述表明，外源性给予儿茶酚胺（在过敏反应或浸润麻醉时注射肾上腺素）和内源性儿茶酚胺分泌过多（嗜铬细胞瘤）均与Takotsubo综合征有关。在各种外科手术中，添加肾上腺素的局部浸润麻醉通常用作血管收缩剂。为降低不良事件风险，建议使用能提供疼痛控制和血管收缩作用的最低有效浓度的肾上腺素。
