A 99-year old patient with takotsubo cardiomyopathy recovering from cardiogenic shock

Takotsubo syndrome (TTS) is a rare clinical entity commonly seen in post-menopausal women after an emotional or sometimes physical stress. This syndrome is thought to be caused by increased circulation catecholamine levels secondary to an adrenergic stimulus resulting in transient coronary spasm and microvascular dysfunction. TTS is characterized by acute and reversible left ventricular dysfunction with the typical ECG and clinical findings of an acute coronary syndrome but no significant coronary stenosis. Typically, in TTS, antero-apical ballooning is observed in ventriculography, and segmentary wall motion abnormalities are observed in magnetic resonance imaging and echocardiography. Acute heart failure, left ventricular outflow tract obstruction, mitral regurgitation and cardiogenic shock may complicate this syndrome. Herein, we present a case who is the oldest one in the literature with TTS and cardiogenic shock.  A 99-year old female patient known to have Alzheimer’s disease admitted to our emergency department with the complaints of acute severe chest pain and dyspnea. She had the signs of acute heart failure with a blood pressure of 70/50 mmHg. In her ECG, ST segment elevation in derivations V2-V6 and D2-D3-aVF, and ST segment depression in V1 and AVR were present (Figure 1). Troponin I level measured at admission was 13 μg/L. Coronary angiography was performed immediately revealing no significant coronary artery disease (Video 1). In the ventriculogram, apical and mid-ventricular ballooning with basal hyperkinesia, typically observed in TTS, was demonstrated (Figure 2, Video 2). In the echocardiography, depressed left ventricular ejection fraction (30%), akinesia and dilatation of the mid and apical portions of left ventricle were seen without an obstruction in the outflow tract (Video 3). Concerning with the diagnosis of TTS and cardiogenic shock, 0, 1