# Biventricular takotsubo syndrome complicated with cardiogenic shock and shark fin sign requiring ECPELLA: a case report

## TL;DR

A 77-year-old woman with biventricular takotsubo syndrome and cardiogenic shock required mechanical circulatory support and showed a rare shark fin sign on her ECG.

## Contribution

This case report highlights the rare combination of biventricular takotsubo syndrome, cardiogenic shock, and shark fin sign requiring ECPELLA support.

## Key findings

- Biventricular takotsubo syndrome can present with cardiogenic shock and shark fin sign.
- Mechanical circulatory support, including Impella and veno-arterial ECMO, may be necessary for severe right ventricular dysfunction.
- Myocardial scintigraphy showed preserved perfusion but reduced MIBG uptake in the acute phase, improving in the chronic phase.

## Abstract

Takotsubo syndrome (TTS) is a transient cardiac condition primarily affecting left ventricular function and is often triggered by physical or emotional stress. Biventricular involvement in TTS has been recently reported, and such cases are associated with a more severe clinical presentation. However, biventricular TTS with cardiogenic shock (CS) requiring mechanical circulatory support (MCS) is rare. Furthermore, shark fin sign (SFS) is a distinctive electrocardiographic pattern typically associated with significant myocardial ischaemia, but SFS associated with TTS has seldom been reported.

A 77-year-old woman with sepsis and pyelonephritis presented with fever and chest pain. An initial electrocardiogram showed SFS. Transthoracic echocardiography revealed a severely reduced left ventricular ejection fraction with apical ballooning, akinesis of the apical free-wall segment, and hyperkinesia of the basal segments of the right ventricle. Impella® was inserted for CS, but the shock persisted due to severe right ventricular (RV) dysfunction, and she required veno-arterial extracorporeal membrane oxygenation. After the treatments, her cardiac functions improved, and MCS was weaned off. The follow-up findings of electrocardiographic changes and Thallium-201 and iodine-123-metaiodobenzylguanidine (MIBG) myocardial scintigraphy were consistent with TTS.

In the case of biventricular TTS with CS, the use of MCS for RV support may be required. Shark fin sign may be associated with haemodynamic instability or shock even in TTS. Furthermore, repeated myocardial scintigraphy is useful for diagnosing TTS because the acute phase shows preserved myocardial perfusion with markedly reduced MIBG uptake indicating impaired sympathetic innervation, whereas the chronic phase shows improvement in MIBG uptake.