(1653) VA ECMO: Battle Cardiogenic Shock Induced by Myxedema Coma-Induced Reverse-Takotsubo Cardiomyopathy

Introduction: Myxedema coma is defined as severe hypothyroidism, which may cause Takotsubo Cardiomyopathy. Herein, we present a myxedema coma-induced rare variant of Takotsubo Cardiomyopathy known as reverse Takotsubo Cardiomyopathy in a premenopausal female and utilization of Veno-Arterial Extracorporeal Membrane Oxygenation (VA-ECMO) to support fulminant cardiogenic shock.

Description: A 28-year-old female with a past medical history of hypothyroidism presented to an outside hospital with chest pain radiating to her jaw. EKG noted ST elevations in the inferior and anterolateral leads and a STEMI alert was called. Left heart catheterization was performed, revealing normal coronary arteries without disease. Bedside transthoracic echocardiogram (TTE) revealed abnormal left ventricular (LV) systolic function, ejection fraction (EF) of 40% with primarily basal hypokinesis and apical hyperkinesis, and severe mid-inferior hypokinesis, pointing towards reverse Takotsubo Cardiomyopathy. She was transferred to an urban tertiary care center.

On arrival, she endorsed that she had not been taking her levothyroxine for 6 months. High-sensitivity troponin T was > 10,000 ng/L. She decompensated, requiring intubation and cannulation for VA-ECMO and intra-aortic balloon pump placement. She was successfully extubated but developed pulmonary edema when off positive pressure, leading to conversion to veno-arterial-venous (VAV) ECMO. Repeat TTE noted a LVEF of 30-35% and she was taken to the operating room for conversion of VAV-ECMO to veno-venous (VV) ECMO with Manta closure of the right femoral artery. Despite full VV-ECMO support, she was unable to wean from the ventilator. Her hospital course was complicated by delirium and the patient unfortunately dislodged her return cannula, leading to hemorrhagic shock associated with hemodynamic decline and arrest. ROSC was achieved after re-cannulation of VA-ECMO, though with this poor prognosis, her family elected to pursue comfort measures and organ donation.

Discussion: Takotsubo Cardiomyopathy and its rare reverse form may be a clinical manifestation of myxedema coma. Our case highlights the supportive efforts ECMO can provide during this pathophysiologic state. It also helps bring awareness to the inherent complications that can exist in this form of cardiogenic shock.