Reverse takotsubo cardiomyopathy induced by adrenaline‐containing irrigation solution during shoulder arthroscopy

Summary

Takotsubo cardiomyopathy is characterised by reversible systolic dysfunction resulting from catecholamine‐induced vasospasm, mainly triggered by intense emotional or physical stress. Adding adrenaline to arthroscopic irrigation solution enhances visibility by minimising bleeding. However, there is a risk of complications due to systemic absorption. Several severe cardiac consequences have been described. Here, we present a case of a patient who underwent elective shoulder arthroscopy involving an adrenaline‐containing irrigation solution. Forty‐five minutes after surgery began, he developed ventricular arrhythmias with hemodynamic instability, necessitating vasopressor support. Bedside transthoracic echocardiography revealed severe left ventricular dysfunction with basal ballooning, and emergent coronary angiography revealed normal coronary arteries. These findings correspond to a reverse variant of takotsubo cardiomyopathy. The patient was transferred to the intensive cardiac care unit sedated, ventilated and hemodynamically supported. Three days following the procedure, he was successfully weaned from vasopressors and mechanical ventilation. Transthoracic echocardiography 3 months after surgery demonstrated complete left ventricular function recovery. Although complications due to adrenaline‐containing irrigation solutions are rare, a growing body of case reports should prompt consideration of the safety of this practice.

Introduction

Over the past two decades, arthroscopy has gained popularity as an effective method of treating various orthopaedic pathologies. Intra‐articular bleeding remains one of the main factors compromising intra‐operative visualisation. Several techniques have been suggested to overcome this issue, including hypotensive anaesthesia, pressure or flow‐controlled irrigation pumps and adrenaline‐containing irrigation solutions. The latter has recently gained popularity since it reduces bleeding and improves visualisation, allegedly without adverse cardiovascular effects [1]. Here, however, we present a case of a patient who underwent elective shoulder arthroscopy involving an adrenaline‐containing irrigation solution and developed a reverse variant of takotsubo cardiomyopathy.

Case report

A 62‐year‐old man underwent elective arthroscopic repair of a right rotator cuff tear. His medical history included idiopathic chronic lymphocytosis and heavy smoking. He had had no previous surgery, was on no medication and had no known allergies. He was assessed to be of American Society of Anesthesiologists' (ASA) physical status 2 with a good functional capacity.

Before induction of anaesthesia, ASA standard monitoring was applied, and near‐infrared spectroscopy was used to measure brain regional oxygen saturation (INVOS™, Medtronic, Minneapolis, MN, USA). Two peripheral venous lines were inserted, and a slow intravenous infusion of Ringer's Lactate solution was initiated.

The patient declined to undergo regional anaesthesia so a general anaesthetic technique was used. Prior to induction of anaesthesia, the patient was administered intravenous midazolam 1 mg, pre‐emptive multimodal analgesia comprising paracetamol 1 g, tramadol 100 mg, magnesium sulphate 2 g, ketorolac 15 mg and dipyrone 1 g, and metoclopramide 10 mg and dexamethasone 4 mg for anti‐emesis. General anaesthesia was induced with intravenous fentanyl 100 μg, propofol 150 mg and rocuronium 70 mg. Following tracheal intubation, anaesthesia was maintained with sevoflurane at 1 MAC. The patient was positioned in the beach chair position. Arthroscopy was conducted with a pressure‐controlled pump system at 50 mmHg, using an adrenaline‐containing irrigation solution (0.33 mg.l⁻¹). Joint exploration revealed a degenerative labrum with a partial tear. Debridement of the joint followed by biceps tenotomy was performed.

Forty‐five minutes after the initiation of surgery and after using approximately 10 l of adrenaline‐containing irrigation solution, the patient suddenly developed premature ventricular beats followed by non‐sustained ventricular tachycardia (Fig. 1). The surgeons were informed, and the operation halted while simultaneously administering intravenous lignocaine 100 mg. The patient was repositioned supine to facilitate further treatment, including applying defibrillator pads. The heart rhythm converted to an accelerated idioventricular rhythm of 90 beats.min⁻¹, with a blood pressure of 220/133 mmHg. Sequentially, the rhythm transformed to narrow complex tachycardia of 160 beats.min⁻¹, which was treated with intravenous esmolol 10 mg. A radial arterial line was inserted, and arterial blood gases and standard cardiac markers were drawn (Table 1). The patient's condition deteriorated rapidly, requiring large doses of noradrenaline (peak dose of 15 μg.kg⁻¹.h⁻¹). A right internal jugular vein central venous catheter was inserted. A consultant cardiologist was called, and the surgeons were asked to close the surgical incision. Bedside transthoracic echocardiography (TTE) revealed moderate to severe left ventricular (LV) dysfunction with a visually estimated ejection fraction of approximately 30%. Significant regional wall motion abnormalities of LV basal and mid regions with apical sparing were noted (Supporting Information, Video S1). A 12‐lead ECG showed sinus rhythm at 90 beats.min⁻¹ (narrow complex); minor ST elevation (0.5–1 mm) in leads I and aVL; minor ST depression (0.5–1 mm) in leads II, III and aVF; and poor R wave progression in leads V1–3. Following multidisciplinary consultation, the patient was transferred to the cardiac catheterisation laboratory. Cardiac angiography revealed non‐obstructive coronary disease (Supporting Information, Video S2). Left ventriculogram findings corresponded to a reverse takotsubo cardiomyopathy (rTCM) variant. The patient was transferred while sedated, ventilated and receiving haemodynamic support with infusions of noradrenaline 3 μg.kg⁻¹.h⁻¹ and vasopressin 2 units.h⁻¹ to the cardiac intensive care unit. Repeated high sensitivity troponin T values rose to 750 ng.l⁻¹ and N‐terminal‐pro‐brain natriuretic peptide to 2460 pg.ml^–1. The patient was treated for congestive heart failure with ramipril (1.25 mg.day⁻¹) and bisoprolol (1.25 mg.day⁻¹). On the second postoperative day (POD), the patient's hemodynamic state improved, and vasopressor support was gradually reduced until complete weaning on POD 3 when the patient's trachea was extubated. On POD 4, the patient was transferred to the cardiology ward and was discharged home on POD 5. Three months after the surgery, a follow‐up TTE demonstrated good LV systolic function with an ejection fraction of approximately 65% (Supporting Information, Video S1).

Figure 1.

Intraoperative continuous ECG monitor. The ECG monitor demonstrates premature ventricular beats followed by non‐sustained ventricular tachycardia and an accelerated idioventricular rhythm that converted to narrow complex tachycardia.

Table 1.

Laboratory findings.

	Intra‐operative (1)	Intra‐operative (2)	POD 1	POD 2
pH	7.18	7.25	7.36	7.4
PaCO2, mmHg	69	59	44	44
PaO2, mmHg	178	138	136	121
HCO3 −, mmol.l−1	26	26	25	27
Hb, g.dl−1	15.1	15.1	14.7	11.8
Creatinine, μmol l.−1	77.81	73.39	61.89	64.55
Urea, mmol.l−1	4.99	5.49	7.65	8.82
Na+, mmol.l−1	134	140	138	139
K+, mmol.l−1	3.1	4.2	5.1	4.3
Lactate, mmol.l−1	3.11	0.67	1.44	1.11
Glucose, mmol.l−1	12.32	7.15	8.54	6.43
Troponin T, ng.l−1	19	642	752	182
NT‐proBNP, pg.ml−1		61	2460

Hb, haemoglobin; NT‐proBNP, N‐terminal‐pro‐brain natriuretic peptide; POD, postoperative day.

Discussion

Takotsubo cardiomyopathy (TCM), commonly known as stress cardiomyopathy, is characterised by significant and reversible systolic dysfunction resulting from catecholamine‐induced vasospasm mainly triggered by intense emotional or physical stress. The clinical presentation often mimics acute coronary syndrome but without evidence of coronary obstruction.

The typical variant is characterised by LV systolic apical ballooning, depressed mid and apical segments, and hyperkinesis of the basal walls (seen in approximately 80% of TCM cases). However, there are several atypical variants, including mid‐ventricular type hypokinesis (14.6%), basal type hypokinesis and apical hyperkinesia (known as rTCM, 2.2%), focal type hypokinesis (1.5%) and global hypokinesis. Additionally, right ventricular dysfunction, along with global LV dysfunction, has also been reported [2, 3]. The recurrence rate and outcomes for rTCM are comparable to those of TCM. The prognosis depends upon the underlying trigger, whether primary or secondary. Emotional or psychological stimuli are the primary form, while physical factors during hospitalisation, such as sepsis, trauma, surgery or critical illnesses, are responsible for the secondary form. The latter is associated with poorer outcomes. Most patients with TCM tend to recover; however, the risk of complications among hospitalised patients is similar to acute myocardial infarction. Mortality rates range from 0 to 8% [3].

Multiple case reports and series have linked TCM to adrenaline use. In their systematic review and meta‐analysis, Nazir et al. reviewed 41 cases of TCM associated with adrenaline administration. They supported the notion that both exogenous and endogenous catecholamines are associated with the pathogenesis of TCM [4].

Though adding adrenaline to irrigation solutions during arthroscopy is currently unlicensed in our healthcare system, it is a common practice to improve visualisation by reducing bleeding. However, risks do exist. Numerous complications have been described resulting from the systemic absorption of adrenaline‐containing irrigation solution during arthroscopy, including posterior reversible encephalopathy syndrome, potentially fatal arrhythmias, severe refractory hypertension and pulmonary oedema [5, 6, 7, 8]. The only case pertaining to TCM during arthroscopy was described by Gicquel‐Schlemmer et al., and the outcome was fatal [9]. As far as we are aware, there is no way to prevent adrenaline from being absorbed systemically, though a low dosage is likely to reduce any risks. Alternative pharmacological methods have been proposed to enhance visualisation without using adrenaline‐containing irrigation solutions; a recent study has indicated that incorporating tranexamic acid into the irrigation fluid during arthroscopic rotator cuff repair could offer comparable visual quality to using adrenaline [10].

We wish to highlight several key learning points: firstly, in addition to the known complications related to surgery and anaesthesia, adding adrenaline to irrigation solutions carries potential risks. Awareness should be raised about this issue among the operating room personnel and simulation‐based training should be provided to prepare for real‐life events. Additionally, since early detection is vital for successful management, vigilance should be maintained when using adrenaline‐containing irrigation solutions. Secondly, timely and effective communication alongside proper teamwork is required to optimise outcomes by gathering multiple resources and taking the appropriate steps. These were particularly noticeable in this case. The team efficiently managed tasks such as closing the surgical wound, initiating arrhythmia treatment, stabilising haemodynamic status, inserting lines and initiating enhanced monitoring, and conducting necessary laboratory and imaging tests. Following a thorough multidisciplinary consultation, the decision was made to transfer the patient to the catheterisation laboratory. Thirdly, point‐of‐care ultrasound is increasingly recognised as a valuable bedside diagnostic tool that provides real‐time assistance in perioperative decision‐making. It is now becoming a standard part of the anaesthesia curriculum in many countries. This case demonstrates the usefulness of bedside TTE in quickly identifying the problem and prompting an urgent consultation with a cardiologist for further evaluation.

Although this is the first case in the literature describing rTCM in this context, it joins a growing body of reports depicting various adverse consequences attributed to this practice. Therefore, although these complications are relatively rare, they should urge the seeking of safer alternative approaches.

Supporting information

Video S1. Intra‐operative and follow‐up transthoracic echocardiography. Intraoperative transthoracic echocardiography demonstrating left ventricle basal ballooning; transthoracic echocardiography three months following the surgery showing complete restoration of left ventricle function.

Video S2. Coronary angiography. Cardiac angiography revealed non‐obstructive coronary disease.