takotsubo   cardiomyopathy , or  transient apical ballooning syndrome  , is a non - ischemic cardiomyopathy that mimics the onset of an acute myocardial infarction .
its incidence was recently reported to be 1.72.2% among patients presenting with acute coronary syndrome .
takotsubo is also called  broken heart syndrome  because a strong emotional psychological stress may act as a potential trigger .
originally described in japan in 1990 , its eponym was coined using the two japanese terms tako ( octopus ) and tsubo ( pot ) , due to the resemblance between the cardiac apical ballooning ( hallmark of the syndrome ) and the octopus trap ( a kind of ceramic pot ) used by japanese fishermen .
the acute functional and instrumental abnormalities accompanying takotsubo cardiomyopathy occur in the absence of significant coronary alterations , and could be completely recovered within a few weeks up to two months . if promptly recognized and correctly managed , despite the severity of its onset and the potentially life - threatening characteristics ( those of a cardiogenic shock ) , this syndrome normally presents a good prognosis with low morbidity and in - hospital mortality rates , , .
this paper reports a rare case of association between takotsubo and hip fracture surgery , which has been described only by two previous studies , .
the female patient we describe , an 81-year - old caucasian woman living at home with a son , was completely independent in katz s basic activities of daily living ( adl  =  6/6 ) and lawton s instrumental activities of daily living scales ( iadl  =  8/8 ) before the hospitalization . her clinical history evidenced osteoporosis with multiple previous vertebral incomplete collapses , in treatment with oral calcium and vitamin d , hypertension controlled with ramipril , and dyslipidemia for which she took statins .
she had no cognitive decline ( normal score at iqcode questionnaire ) , allergies , or weight loss .
the woman was admitted during night time in the emergency department ( ed ) of san gerardo university hospital after an accidental fall at home , reporting trauma of the right hip .
1a ) and partial collapse of multiple vertebrae , the latter without evidence of recent fractures .
no significant abnormalities were reported at the blood examinations ( i.e. , blood count , electrolytes , liver and kidney function indexes , protein electrophoresis , coagulation parameters , blood gases ) or at the standard electrocardiogram ( ecg , fig .
the patient was firstly admitted in the orthopedic ward , and then transferred to the orthogeriatric unit ( ogu , within the geriatric ward ) the day after , once the geriatricians confirmed the eligibility criteria for admission .
the comprehensive geriatric assessment did not reveal cognitive deterioration or delirium ( 4at score  =  2/12 ) .
the pain was on average well controlled with the standard protocol of treatment ( acetaminophen 1  g three times intravenously / day ) .
score  =  2 ) , which was performed 60  h after the admission .
ten minutes after the injection of cement , when the orthopedic surgeons were performing haemostatic maneuvers and a check of joint movements , the surgical act was complicated by severe bradycardia and cardiogenic shock with consequent cardio - pulmonary arrest . without perturbing the sterility of the surgical site ,
the patient was placed supine and promptly treated with cardiopulmonary resuscitation maneuvers , oro - tracheal intubation , and intravenous administration of atropine and epinephrine , obtaining return of spontaneous circulation after 7  min .
upon restoration of spontaneous circulation , the surgical procedure was completed with saline washing , local instillation of tranexamic acid , layered suture , and plain medication with plaster . the first suspected diagnosis , considering the time relationship with cement injection , was  bone cement implantation syndrome ( bcis )  .
the patient was then transferred from the operating theater to the intensive care unit ( icu ) , where dopamine ( 5.33  mcg / kg / min , increased to 16  mcg / kg / min ) and norepinephrine ( 0.060.13  mcg / kg / min ) were administered intravenously reaching treatment maximization .
hydroelectrolytic solutions ( 3500  ml ) were infused to increase the circulating volume and furosemide 40  mg iv was administered to stimulate the diuresis . in the absence of clinical benefits , due to the persistence of hypotension ( systolic blood pressure  =  80  mmhg , mean arterial pressure  =  50  mmhg ) and the presence of sinus tachycardia , the anesthetist added bisoprolol 1.25  mg four times / day .
the echocardiography revealed akinesia of the apex and the mid segment of the septum , extending to the anterior and infero - lateral cardiac wall , accompanied by apical ballooning and significant reduction of the left ventricular ejection fraction ( lvef  =  25%30% during amine iv infusion ) .
additional examinations excluded the presence of cerebrovascular diseases , myocarditis , hypertrophic cardiomyopathy , and pheocromocytoma .
these results oriented toward a diagnosis of takotsubo syndrome , so that the cardiologist prescribed iv treatment with heparin ( 2000  ui in bolus  +  20,000  ui in 24  h ) , gradually reduced and discontinued the aminic support , and positioned an intraortic balloon pump .
the day after surgery , despite an observed initial reduction of the troponin t levels ( ctnt  =  185  ng / ml after 24  h , 154  ng / ml after 32  h ) , the echocardiography showed further reduction of the lvef ( 20% ) with apical akinesia in toto .
the finding of anemia ( hb  =  8.5  g / dl , mcv  =  78.5  fl ) was corrected with the transfusion of 2 units of concentrated red blood cells .
on the second post - operative day , considering the persistence of low cardiac output and atrial tachycardia , the patient started iv treatment with levosimendan 0.1  mcg / kg / min for 7  h , amiodarone 907  mcg / day and metoprolol 2  mg , with gradual amelioration of cardiac output and heart rate . during the third post - operative day we discontinued iv treatment with heparin
, we removed the intraortic balloon pump and the oro - tracheal device , supporting the patient with low - intensity oxygen by mask .
therapy with acetylsalicylic acid 100  mg / day and captopril 6.25  mg three times / day was initiated . on the fourth post - operative day
we report a single episode of hyperactive delirium occurred during the night , efficiently managed with the administration of haloperidol 2  mg intramuscular  +  quetiapine 50  mg per os . during the fifth post - operative day
she was transferred to the cardiology icu , where she underwent echocardiography re - evaluation that showed significant restore of the contractile function ( lvef  =  56% ) . on the seventh post - operative day
the patient was transferred back to the ogu , where she started specific physical therapy oriented towards passive and active mobilization of the right leg , achievement and maintenance of the standing position , and ambulation with the support of a walker . before discharge ,
the hemoglobin levels were stabilized ( hb  =  12.3  g / dl ) . during the hospital
she was discharged sixteen days after the operation and the takotsubo syndrome , in good physical and mental conditions ( mmse score   before discharge  =  25/30 ) , able to walk ( walker  +  supervision ) without pain in the surgical area .
the follow - up performed two months after surgery revealed absence of cardiac symptoms and good recovery of the walking ability with a walking stick .
we suggested to continue strengthening the lower limb muscles with domiciliary physiotherapy and allowed walking without any aid . at the 6-month follow - up , the woman was still asymptomatic from a cardiovascular point of view .
she reached a functional level comparable with the pre - fracture status ( katz s adl  =  6/6 , lawton s iadl  =  7/8 ) .
she was able to walk without aids at home , but she needed a walking stick when going outside because of a residual fear of falling .
finally , the echocardiogram confirmed good cardiac function ( lvef  =  55% ) in the absence of other abnormalities . her son , the caregiver living with her , confirmed an overall good functional and nutritional status and no signs of cognitive decline compared with the pre - fracture status .
the patient fulfills several criteria for a diagnosis of takotsubo syndrome : physically stressful event as a trigger , female elderly patient ( at higher risk than young subjects and males ) , apical ballooning with akinesia ( echocardiogram ) , st - segment alterations immediately after the onset ( electrocardiogram ) , lack of significant coronary artery stenosis , recovery of the left ventricular function . indeed
, approximately 90% of the cases occur in the female population , mostly between 58 and 75 years of age , though it is not uncommon among older individuals , . in this case report
, the symptomatology seemed to be triggered by the injection of pressurized cement during the hemiarthroplasty procedure , mimicking a bcis of grade 3 ( the more severe grade ) with acute myocardial infarction , accompanied by the classic instrumental cardiac findings .
bcis was previously reported to be a sporadic adverse event of bone cement injection , still incompletely understood , and was defined only recently .
it is characterized by the association of multiple signs of different severity , which contribute to a heterogeneous presentation : hypoxia , hypotension , alteration of vascular pulmonary resistance , cardiac arrhythmias , and cardiac arrest . however , in this case , the coronary angiography did not show major obstructions or arterial abnormalities , and the echocardiography did not demonstrate the presence of emboli , thus suggesting a different diagnosis and orienting the physicians toward takotsubo cardiomyopathy .
this is the second case of takotsubo we recently encountered in our medical practice , the first being described in 2012 in an 80-year - old woman with severe alzheimer s disease .
pathophysiological mechanisms underlying takotsubo are still not well understood , and the reported cases suggest a number of potential etiologies . in several cases a multifactorial mechanism might be involved , and different variants of the classic takotsubo syndrome have been progressively described , , . altogether , a single pathophysiological mechanism does not clarify the existence of several takotusbo s variants .
hip fracture and the related surgery are even more stressful experiences : healthcare professionals working in this area should be aware of the severe physical ( pain , immobility , functional disability ) and psychological / emotional ( transfers , total dependence , anxiety ) burden that affects the geriatric population .
strength of our approach was the availability and coordination of multiple specialists as consultants 24/24  h , with the geriatrician as the primary attendant according to our orthogeriatric protocol of co - management .
these allowed to set up promptly the necessary support therapies and instrumental evaluations in order to identify the potentially life - threatening diagnosis .
limitations include the initially wrong diagnostic orientation and the resources required to complete the differential diagnosis before confirming the takotsubo .
despite being a rare condition , takotsubo syndrome is a possible differential diagnosis of the bcis , which recently emerged 
regardless its severity  as a frequent complication of surgical orthopedic procedures involving the pressurized injection of bone cement , with a prevalence of about 2530% , . moreover , porto et al .   recently reviewed the correlation between neurologic disorders and transient left ventricular dysfunction , called neurogenic stunned myocardium and characterized by findings which resemble the classic takotsubo cardiomyopathy .
the authors concluded that the available literature suggests treating them as different entities . to the best of our knowledge , the association of takotsubo syndrome with hip fracture in the preoperative phase   or after surgery   has been rarely reported ( two cases ) .
, the correct management of elderly subjects could potentially reduce the stress experience related with hip fracture . promoting the  gentle care 
informed consent for the acquisition of data to present in this case report was obtained during the hospitalization , and signed by the patient itself .
the consent form is stored in the archive of san gerardo university hospital ( monza , italy ) .
written informed consent was obtained from the patient for publication of this case report and accompanying images .
a copy of the written consent is available for review by the editor - in - chief of this journal on request .
all demographic and patient - specific personal information have been de - identified according to the italian law for the privacy and protection of personal information (  codice in materia di protezione dei dati personali , d. lgs .
dp , mc , and gb took care of the patient during the hospitalization and obtained informed consent for this report .
 highlightsdespite the good prognosis when diagnosed early , takotsubo is a life - threatening event.takotsubo must be differentiated from bone cement implantation syndrome ( grade 23).a portable ultrasound scanner allows recognizing the apical ballooning and akinesia hallmark.approaches to reduce the hospitalization - related stress must be pursued in the elderly . 