Takotsubo cardiomyopathy with cardiogenic shock misdiagnosed as old MI, successfully treated with TAVR: a case report

Background: Differentiating Takotsubo cardiomyopathy (TCM) from myocardial infarction (MI) remains challenging, especially in elderly patients with structural heart disease. When complicated by severe aortic stenosis (AS), cardiogenic shock can rapidly develop, posing both diagnostic and therapeutic dilemmas. Case summary: A 91-year-old woman presented with progressive dyspnoea and was admitted for acute decompensated heart failure. Transthoracic echocardiography revealed severe AS and a reduced left ventricular ejection fraction (LVEF) of 30% with apical wall thinning, suggestive of an old MI. Despite optimal medical therapy, she developed recurrent syncope and was referred for transcatheter aortic valve replacement (TAVR). Before the scheduled procedure, the patient developed cardiogenic shock and pulseless electrical activity. Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was initiated, and emergency TAVR was performed. The patient's haemodynamics stabilized, with subsequent clinical recovery. Coronary angiography revealed no obstructive coronary disease, and left ventriculography demonstrated apical ballooning consistent with TCM. The patient was weaned from ECMO, with a subsequent improvement in LVEF. She was discharged to a rehabilitation facility. Discussion: The present case highlights the diagnostic challenge of distinguishing TCM from ischaemic heart disease in elderly patients with severe AS and underscores the importance of prompt, multidisciplinary decision-making in managing cardiogenic shock. Furthermore, ECMO-supported TAVR may represent a viable life-saving option in selected high-risk patients.