Biventricular Takotsubo Cardiomyopathy in a Heart Transplant Recipient

A 64-year-old man who had undergone cardiac transplantation for ischemic cardiomyopathy 9 years earlier was admitted to the hospital for malaise and fever of unknown origin. His posttransplantation course had been complicated by transplant vasculopathy requiring percutaneous coronary intervention 2 years earlier. His immunosuppressant regimen included cyclosporine, mycophenolate mofetil, and low-dose steroids. On admission, he denied having chest pain, but his high-sensitivity troponin I level was elevated at 17 µg/L (normal range, 0–0.045 µg/L). His ECG was unremarkable. Echocardiography demonstrated extensive posterior wall akinesia but no other regional wall motion abnormalities. Ejection fraction was estimated at 60%. Urgent coronary angiography demonstrated subtotal occlusion of the left circumflex artery. Appropriate antibiotic therapy was initiated, and possible sources of infection were ruled out by transesophageal echocardiography and thoracoabdominal computed tomography scan. Two days later, the patient was taken back to the catheterization laboratory and treated by implantation of a drug-eluting stent.One week later, while still in the hospital, he developed sudden onset of dyspnea accompanied by a drop in oxygen saturation …