Takotsubo syndrome treated with VA-ECMO in plastic surgery: echocardiography first-case series.

Background: Takotsubo syndrome is a transient cardiac disease induced by emotional or physical stress secondary to sympathetic hyperstimulation resulting in regional wall motion abnormalities. Secondary subtypes appear to affect younger patients and reveal in more severe presentations where difficulties in diagnosis and management may arise. Real-world scenarios may significate a literature tool for referral and consideration in certain contexts. Case Summary: Four previously healthy young women (28, 27, 31, and 34 years old) underwent different plastic surgery procedures, presenting haemodynamic instability in the operating room. Transoesophageal echocardiography showed left ventricular ballooning and decreased systolic function, resembling Takotsubo morphology. All four patients developed refractory cardiogenic shock, and mechanical circulatory support was initiated with later complete left ventricle global mobility normalization and 100% survival. Discussion: Surgery has been associated as a trigger factor for this syndrome. However, the number of cases related to aesthetic procedures is probably underestimated. Beyond this under-recognition, factors such as the administration of exogenous catecholamines, simultaneous multiple procedures, and prolonged surgical times in patients with an underlying vulnerability may account for the more severe clinical manifestations observed in this setting. Therefore, risk factors screening, prompt identification, and early treatment including mechanical circulatory support, could decrease the mortality rate in these patients. In addition to current algorithms for Takotsubo syndrome, we propose transoesophageal or transthoracic echocardiography as the primary diagnostic tool. Its early use allows prompt recognition and timely intervention, which are key factors for survival in cardiogenic shock.