A healthy 63-year-old woman with no cardiovascular risk factors was admitted to the emergency room with new-onset dyspnoea and fever. The symptoms started 1 day after receiving the first of two mRNA-1273 (Moderna, Cambridge, MA, USA) COVID-19 vaccinations. She had no other prior complaints. A retronasal severe acute respiratory syndrome coronavirus 2 polymerase chain reaction test was negative. Laboratory tests revealed normal results for creatinine, creatine kinase, and creatine kinase MB (myocardial type). High-sensitivity troponin T was elevated at 320 ng/L (normal: <14 ng/L), and N-terminal pro-B-type natriuretic peptide was highly elevated at 10,180 pg/mL (normal: <284 pg/mL). C-reactive protein was elevated, but the leucocytes were within the normal range at 8.44 g/L (reference interval [RI]: 3.00–10.5 g/L). Urine and blood cultures were negative. Computed tomography scan of the chest revealed no pulmonary embolism but did show signs of heart failure. An electrocardiogram showed negative T waves over the inferior/anterior leads. Invasive coronary angiography ruled out coronary artery disease, but the ventriculogram (Figure 1 ) showed mid-ventricular to apical ballooning (asterisk) with preserved basal contraction (blues arrows) and a moderately impaired left ventricular ejection fraction of 40%. Apical ballooning was confirmed by echocardiography and cardiac magnetic resonance imaging (CMR). CMR tissue characterisation further depicted extensive oedema in the mid-ventricular/apical segments (i.e., T2-weighted imaging in the myocardium vs skeletal muscle with a signal intensity ratio of >2.0), elevated T2 mapping at 56 ms (RI: 42–50 ms), elevated T1 mapping at 1,158 ms (RI: 903–1,059 ms), and the extracellular volume fraction was elevated at 35% (RI: 25±4%). There was no late gadolinium enhancement suggesting peri-/myocarditis and no pleural or pericardial effusion. As there were no other stressors that could be determined to be underlying the midventricular/apical oedema and ballooning, the most probable diagnosis of COVID-19 vaccine-induced Takotsubo cardiomyopathy (TCM) was made. Although myocarditis is a possible differential diagnosis after COVID-19 vaccination [1], the clinical and investigative features of this case were strongly suggestive of TCM. There have been rare reports of TCM after influenza vaccination [2,3], with an underlying pathophysiology of systemic inflammatory stress reaction after vaccination with a sympathovagal imbalance towards adrenergic predominance [4]. TCM confirmed by CMR after a COVID-19 vaccination has not yet been reported and may be considered as a differential diagnosis besides myocarditis in this clinical setting.
Figure 1.
Multimodality imaging using ventriculography, Echocardiography and cardiac magnetic resonance of Takotsubo cardiomyopathy after COVID-19 mRNA vaccination.
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