Sudden Death in a Case of Recurrent Takotsubo Syndrome 

Takotsubo syndrome (TS), otherwise known as broken heartsyndrome or stress cardiomyopathy, represents an acute andusually reversible heart failure syndrome characterized by leftventricular dysfunction; however, its substantial morbidityand mortality has been recognized in recent years [1]. Firstdescribed in Japan in 1991, this syndrome is named after theJapanese word for a kind of octopus (Tako) trap (Tsubo),because the left ventricle in TS takes a shape resembling thisoctopus fishing pot.Takotsubo syndrome diagnosis requires the echocardio-graphic demonstration of acute left ventricle (LV) apex bal-looning, in association with normal coronary artery angiogra-phy; minor diagnostic criteria include limited or no elevationof the cardiac enzymes, precordial pain, physical or emotionalstress as triggering factors 
Herein we report an unusual case of sudden death occurring in a 65 year old woman during a minor oral surgery. The subject, whohad a medically treated anxiety, had a history of two reversible left ventricle dysfunction episodes consistent with recurrentTakotsubo Syndrome that had occurred seven and six years before, respectively. She also suffered from moderate, well treatedpost-menopausal systemic hypertension. Post-mortem examination showed apical biventricular ballooning of the heart with nocardiac rupture, coronary artery lesion or other cardiac/extra-cardiac disease. Toxicological tests and forensic investigationsexcluded unnatural causes of death, including pharmacological or iatrogenic causes related to medical malpractice. Only non-specific contraction bands and mild hypertrophy were observed by histology in the left ventricle myocytes. Takotsubo syndromeis usually an acute and reversible heart failure syndrome with acute left ventricle apex ballooning, no coronary artery disease orother macroscopic or microscopic cardiac changes; physical or emotional stress are well known triggering factors. Nevertheless,recurrent forms, major cardiac adverse events and even sudden death may occur in a minority of cases, meaning that a diagnosisof Takotsubo syndrome must be considered in cases of sudden death and in forensic investigatio