Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review

Near-drowning syndrome: a possible trigger of tako-tsubo cardiomyopathy

We report a case of transient tako-tsubo cardiomyopathy characterized by an unusual trigger in a woman victim of near-drowning syndrome. After 24 h, electrocardiogram changes and a typical echocardiographic pattern of apical ballooning with a mild increase of serum troponin level induced the suspicion of tako-tsubo cardiomyopathy despite the absence of chest pain. Left ventriculography confirmed the apical ballooning, and coronary angiography revealed normal coronary arteries. Electrocardiogram changes and apical contraction abnormalities were reversed within 1 month. In conclusion, we hypothesize that hypoxemia related to near-drowning syndrome could have induced transient myocardial dysfunction mediated by a sympathetic nerve activation.

Thromboembolism in Takotsubo cardiomyopathy

BACKGROUND

Most patients with Takotsubo cardiomyopathy show a favorable outcome. Although several complications have been reported, the frequency of thromboembolism has not been clarified.

METHODS

Clinical characteristics and complications of 21 consecutive patients (18 female, aged 72 years) with Takotsubo cardiomyopathy during the past 9 years were investigated.

RESULTS

The most major complication was heart failure (52%). Thromboembolism was found in 3 patients (14%) and this was the second most frequent cardiovascular complication. One of the 3 patients showed left ventricular thrombus and the other 2 experienced cardioembolic stroke. All 3 patients visited the emergency department more than 48 h after initial chest pain occurred.

CONCLUSIONS

This study indicates that thromboembolism is a common complication in the acute phase of Takotsubo cardiomyopathy, and anticoagulation therapy should be performed in all patients until wall motion abnormalities improve. Takotsubo cardiomyopathy should be considered one of the important causes of cardioembolic stroke.

Can peripartum cardiomyopathy be familial?

Peripartum cardiomyopathy (PPCM) is a rare disorder, with four principal features: 1--development of cardiac heart failure in the last month of pregnancy or within five months after delivery, 2--absence of an identifiable cause for heart failure, 3--absence of underlying heart disease prior to the last month of pregnancy, 4--evidence of left ventricular systolic dysfunction by classic echocardiographic criteria. Reported forms of familial peripartum cardiomyopathy are exceptional. Our observation emphasizes the interest of cardiac magnetic resonance imaging (MRI) in the investigation of an acute heart failure occurring during the peripartum and allows us to evoke a genetic predisposition in some cases of PPCM, to discuss the fact that some forms of familial PPCM could be unknown familial dilated cardiomyopathy unmasked by pregnancy, and to wonder on the familial screening modalities.

Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: a systematic review

BACKGROUND

Though a severe left ventricular systolic dysfunction has been described in most patients with Takotsubo-like (or Apical Ballooning) syndrome, the occurrence of intra-cavitary thrombus formation seems to be such an exceptional finding. However, no large studies but single case descriptions of this complication are available over the last decade in the literature.

METHODS

By searching for the PubMed-Medline database we selected 14 studies that met our eligibility criteria.

RESULTS

Demographic, clinical and morphofunctional characteristics of 15 patients who where described to have left ventricular thrombosis as a complication of the Takotsubo-like syndrome are comprehensively described in this review. Cardioembolic complications (stroke in 3 cases, renal infarction or popliteal artery thrombosis in other two) occurred in 33.3% out of them. The incidence of thrombus formation and related systemic embolisms in the general population with this syndrome were established on the basis of such available historical data and reviews on this subject.

CONCLUSION

Left ventricular thrombus formation has been reported in at least 14 studies (15 patients) over the last decade until the end of 2007. This approximately results in about 2.5% of all the patients with documented Takotsubo-like syndrome. Cardioembolic complications occurred in 5/15 cases, corresponding to 0.8% of the whole known population.

Long-term prognosis of the transient left ventricular dysfunction syndrome (Tako-Tsubo cardiomyopathy): focus on malignancies

BACKGROUND

The pathophysiology and long-term prognosis of the transient left ventricular dysfunction syndrome (LVDS, Tako-Tsubo cardiomyopathy) is largely unknown.

AIMS

To investigate the prevalence of malignancies and long-term mortality in patients with LVDS.

METHODS AND RESULTS

Fifty patients with LVDS (47 females and 3 men, age 70+/-10 years) and 50 age- and gender-matched control patients with acute anterior myocardial infarction (MI) were evaluated. Nine patients (18%) with LVDS and 3 patients (6%) with MI had a previous history of malignancy at the time of the index event. On follow-up (2.9+/-1.6 years), 7 malignancies were newly diagnosed in the LVDS cohort whereas no new case of malignancy was found in the control group (p=0.01, odds ratio 16.95, 95% confidence interval [CI] 1.93-304.60). Overall mortality during follow-up did not differ significantly between both groups (hazard ratio 1.44 for death in LVDS patients, 95% CI 0.52-3.95, p=0.49); however, of those patients who died, cardiac deaths were more frequent in patients with MI (100% versus 11% in patients with LVDS, p<0.001).

CONCLUSIONS

Our data suggest an association of LVDS with malignancies, potentially as a result of paraneoplastic phenomena. Long-term prognosis of patients with LVDS is no better than in patients with acute MI.

Cardiogenic shock secondary to Tako-tsubo syndrome after debridement of malignant endobronchial obstruction

Transient left ventricular (LV) dysfunction syndrome, or Tako-tsubo syndrome, occurs following intense emotional or physical stress and simulates the clinical presentation of an acute myocardial infarction. We report a case of a 77-year-old man with esophageal adenocarcinoma with local invasion of the central airways who underwent rigid bronchoscopy for tumor debridement followed by placement of a stent. Postoperatively, cardiogenic shock developed and echocardiography revealed akinesis of the LV apex with an ejection fraction (EF) of 15%. Emergent coronary angiography revealed no significant coronary artery disease. The patient required intraaortic balloon counterpulsation and pressors. Seventy-two hours later, repeat echocardiography showed an EF of 45% with improvement in apical function, and the patient was discharged home in stable condition shortly thereafter. A 5-month follow-up echocardiogram revealed an EF > 55%, and the patient enjoyed an excellent performance status.

Nearly asymptomatic left ventricular apical ballooning after a hit-and-run accident

Tako-tsubo cardiomyopathy is a syndrome that mimics acute myocardial infarction consisting of typical chest pain with acute onset and transient left ventricular wall-motion abnormalities. We present a case of a 53-year-old woman with nearly asymptomatic apical ballooning after a hit-and-run car accident. No blunt force impact occurred over the precordial area. Typical chest pain or dyspnea was not present at any time. Electrocardiogram showed ST-segment elevation and T-wave inversion. Cardiac catheterization revealed the absence of coronary stenosis. Whereas left ventriculography and cardiac magnetic resonance imaging showed apical akinesia and hypercontractility of the basal segments (apical ballooning). Left ventricular systolic function recovered from ejection fraction 34% to 55% in ten days and echocardiographic wall abnormalities returned to normal.

Ventricular arrhythmias during Tako-tsubo syndrome

Tako-tsubo syndrome is a recently described form of cardiomyopathy. Its pathophysiology remains unknown. However, the main demographic, clinical, electrocardiographic and biologic characteristics of the disease have been described by previous reports. Retrospective studies are essential to help describe this rare disease, although they might have several skews. Previous reports have observed a mortality rate between 0 and 8%. In our serie, demographic, clinical, electrocardiographic and biologic results are similar with those previously reported. However, the mortality rate observed was higher than expected. Refractory ventricular arrhythmias leading to death have been encountered in 15% of patients. Tako-tsubo syndrome may present as sudden death and its mortality rate may have been underestimated in previous reports.

Out-of-hospital cardiac arrest caused by transient left ventricular apical ballooning syndrome

We describe a case of out-of-hospital cardiac arrest due to ventricular fibrillation in a patient with transient left ventricular apical ballooning syndrome. Our report confirms that left ventricular apical ballooning may have the same complications of myocardial infarction, adding the early ventricular fibrillation to the previous findings of left ventricular wall rupture, ventricular arrhythmias during hospitalization and complete atrio-ventricular block. Moreover, left ventricular apical ballooning may have different and unusual clinical onsets, including sudden cardiac death due to ventricular tachyarrhythmias in the absence of associated symptoms. Therefore, in our opinion left ventricular apical ballooning may be considered as a possible cause of sudden death in otherwise healthy women.

Takotsubo cardiomyopathy complicated by Dressler's syndrome

Takotsubo cardiomyopathy is an increasingly recognised syndrome characterised by transient apical left ventricular dysfunction in the absence of significant coronary artery disease. We describe a case of Takotsubo cardiomyopathy complicated by Dressler's syndrome. To our knowledge, these two conditions have not previously been reported in combination.

Reversible impairment of coronary flow reserve in takotsubo cardiomyopathy: a myocardial PET study

BACKGROUND

The precise etiology of takotsubo cardiomyopathy remains unclear. The study of myocardial blood flow (MBF) and coronary flow reserve (CFR) by use of positron emission tomography might help in understanding this syndrome.

METHODS AND RESULTS

Three postmenopausal women underwent adenosine/rest perfusion with nitrogen 13 ammonia and metabolism with fluorine 18 fluorodeoxyglucose positron emission tomography, coronary angiography, cardiac magnetic resonance, and echocardiography in the acute phase of takotsubo cardiomyopathy and at 3 months' follow-up, after normalization of left ventricular function. PET study was performed in 2 parts: the perfusion analysis with nitrogen ammonia and the metabolism of the heart using FDG. MBF and CFR were analyzed quantitatively in the acute phase and at follow-up. The images highlighted the impairment of tissue metabolism in the dysfunctioning left ventricular segments in the acute phase, mainly in the apical segments and progressively less in the medium segments. At the same time, a clear inverse metabolic/perfusion mismatch emerged, which normalized 3 months later. The quantitative analysis of MBF showed a reduction in the acute phase in apical segments in comparison to basal segments without differences between midventricular and basal segments. In the acute phase CFR proved to be reduced in apical versus basal segments. CFR impairment of apical segments recovered completely after 3 months.

CONCLUSION

The acute phase of takotsubo cardiomyopathy is characterized by an inverse perfusion/metabolism mismatch with a reduction in CFR in the apical segments. However, the impairment of CFR and the reduction of metabolism in the apical segments recovered completely after 3 months.

Reversible impairment of coronary flow reserve in takotsubo cardiomyopathy: a myocardial PET study

BACKGROUND

The precise etiology of takotsubo cardiomyopathy remains unclear. The study of myocardial blood flow (MBF) and coronary flow reserve (CFR) by use of positron emission tomography might help in understanding this syndrome.

METHODS AND RESULTS

Three postmenopausal women underwent adenosine/rest perfusion with nitrogen 13 ammonia and metabolism with fluorine 18 fluorodeoxyglucose positron emission tomography, coronary angiography, cardiac magnetic resonance, and echocardiography in the acute phase of takotsubo cardiomyopathy and at 3 months' follow-up, after normalization of left ventricular function. PET study was performed in 2 parts: the perfusion analysis with nitrogen ammonia and the metabolism of the heart using FDG. MBF and CFR were analyzed quantitatively in the acute phase and at follow-up. The images highlighted the impairment of tissue metabolism in the dysfunctioning left ventricular segments in the acute phase, mainly in the apical segments and progressively less in the medium segments. At the same time, a clear inverse metabolic/perfusion mismatch emerged, which normalized 3 months later. The quantitative analysis of MBF showed a reduction in the acute phase in apical segments in comparison to basal segments without differences between midventricular and basal segments. In the acute phase CFR proved to be reduced in apical versus basal segments. CFR impairment of apical segments recovered completely after 3 months.

CONCLUSION

The acute phase of takotsubo cardiomyopathy is characterized by an inverse perfusion/metabolism mismatch with a reduction in CFR in the apical segments. However, the impairment of CFR and the reduction of metabolism in the apical segments recovered completely after 3 months.

Transient apical ballooning syndrome--clinical characteristics, ballooning pattern, and long-term follow-up in a Swiss population

BACKGROUND

Transient apical ballooning syndrome (TABS) or Takotsubo cardiomyopathy mimics acute ST-elevation myocardial infarction, but is considered to have a good prognosis with only moderate elevation of myocardial enzymes and full recovery of left ventricular function. Although it is increasingly reported, its exact incidence, clinical presentation, and prognosis in non-Asian populations remain largely unknown.

OBJECTIVE

To describe the clinical characteristics and long-term follow-up of patients who presented with TABS at our institution over a 3 year-period.

METHODS

Patients were retrospectively retrieved from our local database. Patient charts were carefully reviewed and the diagnosis of TABS was based on the Mayo Clinic diagnostic criteria. Moreover, psychosocial stress or gastrointestinal disease was recorded.

RESULTS

During the study period, 13,715 coronary angiographies were performed at our institution, including 2459 patients presenting with an acute coronary syndrome (ACS). Forty-one TABS were diagnosed, which represents an incidence of 1.7% of ACS-patients and 0.3% of all coronary angiographies performed, respectively. Mean age was 65 years, with 85% women. Clinical presentations included chest pain, dyspnoea, and cardiogenic shock. A preceding psychological or physical condition perceived as "stress" was reported in 61%. At a mean follow-up of 675+/-288 days, none of the patients died of cardiac causes, but two patients had a recurrence of symptoms.

CONCLUSIONS

This is the largest cohort of TABS patients reported out of Europe so far. The good overall prognosis and low likelihood of recurrence were confirmed.

Takotsubo cardiomyopathy may be associated with cardiac geometric features as observed in hypertensive heart disease

Takotsubo cardiomyopathy is a clinical entity with a relatively new described acute and reversible left ventricular (LV) dysfunction triggered by emotional stress. Different observations have represented that takotsubo cardiomyopathy may be associated with similar LV myocardial geometry as described by novel quantitative echocardiographic methods in hypertensive heart disease. Therefore, acute emotional stress in takotsubo cardiomyopathy or chronic stress by increased afterload in hypertension possibly represents similar morphologic and functional features on the basis of heart.

Review of acute coronary syndrome diagnosis and management

Acute coronary syndrome (ACS) refers to a group of clinical conditions caused by myocardial ischemia including unstable angina, non-ST-segment elevation myocardial infarction (NSTEMI), and ST-segment elevation myocardial infarction (STEMI). Appropriate and accurate diagnosis has life-saving implications and requires a quick but thorough evaluation of the patient's history, physical examination, electrocardiogram, radiographic studies, and cardiac biomarkers. The management of patients with suspected or confirmed ACS continues to evolve as new evidence from clinical trials is considered and as new technology becomes available to both primary care physicians and cardiologists. Low- and intermediate-risk patients have frequently been managed in a chest pain center or in the emergency department. While stress testing with or without radionuclide imaging is the most common evaluation method, a CT angiogram is sometimes substituted. High-risk patients are often managed with an early invasive strategy involving left heart catheterization with a goal of prompt revascularization of at-risk, viable myocardium. With the increased availability of cardiac catheterization facilities, patients with STEMI are more commonly being managed with primary percutaneous coronary intervention, although thrombolysis is still used where such facilities are not immediately available. This article provides primary care physicians with a concise review of the pathophysiology, clinical evaluation, and management of ACS based on the best available evidence in 2008.

Takotsubo cardiomyopathy: pathogenetic insights and myocardial perfusion kinetics using myocardial contrast echocardiography

Transient apical ballooning syndrome or Takotsubo cardiomyopathy (TC) is a novel acute cardiac syndrome, characterized by regional systolic dysfunction involving the apex and mid-ventricular segments, with hyperkinesis of the basal segments. Mid-ventricular ballooning cardiomyopathy (MVBC) is a recently recognized variant of TC. Both disorders share the same precipitating factors, clinical features and course; however, unlike TC, MVBC is characterized by ballooning and akinesis of the mid-ventricular segments with hypercontractility of the basal and apical segments. While the precise pathogenetic mechanism of this disorder remains elusive, microvascular dysfunction from excessive catecholamine release has been implicated. We report findings on regional contractile dysfunction (strain imaging), myocardial blood flow (semi-quantitative), and perfusion kinetics using myocardial contrast echocardiography in a series of three illustrative cases of TC.

Ventricular repolarization gradients in a patient with takotsubo cardiomyopathy

A 61-year-old woman had recurrent syncopal attacks caused by torsades de pointes associated with remarkable QT prolongation (QTc = 740 ms). Left ventriculography showed apical akinesis (ballooning) and basal hyperkinesis, but coronary angiography was normal. This was compatible with takotsubo cardiomyopathy. The wall motion of the left ventricle (LV) normalized within 2 months, and the remarkable QT prolongation and negative T-waves gradually normalized. However, polymorphic ventricular tachycardia recurred at 2.5 months after its initial onset, and we measured repolarization gradients using activation recovery intervals (ARIs) in an electrophysiological study. During atrial pacing at a cycle length of 1000 ms, the negative T-waves were observed in leads II, III, aVF, and V2-6 with QT prolongation, and the ARIs in both the epicardium and the endocardium increased from the basal site to the apical site. Moreover, the ARI tended to be longer in the epicardium than the endocardium at each level of the LV. In contrast, atrial extrastimulation changed the T-wave morphology (from negative to biphasic) in leads II, III, aVF, and V2-6 and changed the ARI gradients both from the LV basal site to the apical site and from the epicardium to the endocardium. These results suggest that the T-wave abnormalities seen in takotsubo cardiomyopathy during sinus rhythm are due to abnormal LV repolarization gradients.

The recurrence of tako-tsubo cardiomyopathy complicated by cardiogenic shock: a case report

Tako-tsubo cardiomyopathy is a stress-related cardiomyopathy which occurs in postmenopausal women after severe emotional stress. Although no evidence supporting specific treatment with tako-tsubo cardiomyopathy has been established, the prognosis is considered favorable with normalization of wall motion abnormalities within weeks. In addition, recurrence of this syndrome seems to be rare. Now, we report a recurrent case of tako-tsubo cardiomyopathy complicated by cardiogenic shock after repeated emotional stress.

Spectrum and significance of electrocardiographic patterns, troponin levels, and thrombolysis in myocardial infarction frame count in patients with stress (tako-tsubo) cardiomyopathy and comparison to those in patients with ST-elevation anterior wall myocardial infarction

Stress (takotsubo) cardiomyopathy (SC) is a recently recognized syndrome with clinical and electrocardiographic (ECG) presentation resembling ST elevation anterior myocardial infarction. As experience with this condition has evolved, a more diverse spectrum of 12-lead ECG patterns has emerged that may affect differential diagnosis. Fifty-nine consecutive patients with SC were prospectively identified at a large community-based cardiology practice. All were women aged 32 to 90 years (mean 66+/-13) with acute chest pain triggered by emotional or physical incidents and with akinesia of the mid-distal left ventricle; each patient recovered and was discharged within a median of 4 days. On electrocardiography, anterior ST elevation was most common (33 [56%]), with magnitudes less than in controls with left anterior descending coronary artery occlusions (1.4+/-1.5 vs 2.4+/-2.2 mm, p<0.001), with considerable overlap. ECG findings in 26 other patients (44%) without ST elevation revealed diffuse T-wave inversion (10 [17%]) and healed anterior infarctions (6 [10%]) or were nonspecific (5 [8.5%]) or normal (5 [8.5%]). Troponin elevations occurred in 56 patients with SC (95%). The mean peak troponin T level was significantly lower in patients with SC (0.64+/-0.86 ng/ml) than in those with left anterior descending coronary artery occlusions (3.88+/-4.9 ng/ml) (p<0.0001). Patients with SC with or without ST elevation did not differ with respect to the ejection fraction (29+/-9% vs 34+/-9%, respectively, p=NS) or Thrombolysis In Myocardial Infarction (TIMI) frame counts. During recovery, diffuse T-wave inversion evolved in 49 patients with SC (83%). In conclusion, patients with SC present with diverse ECG findings, and no single pattern alone can reliably distinguish this condition from acute coronary syndromes. The diagnosis of SC requires heightened awareness of its unique clinical profile as well as coronary arteriography and left ventriculography.

Myocardial infarction with angiographically normal coronary arteries in the contemporary era

BACKGROUND

Myocardial infarction with angiographically normal coronary arteries (MINC) is a well recognized clinical entity, but limited data regarding outcome and prognostic factors exist in the literature. This study sought to identify clinical characteristics and etiological factors as well as outcome predictors in patients with MINC.

DESIGN

Retrospective follow-up study.

METHODS

Fifty-eight patients presenting with MINC fulfilled the study inclusion criteria. Clinical characteristics, cardiovascular risk factors, and etiologic and laboratory data were harvested and compared with those obtained from patients with myocardial infarction and single vessel coronary artery disease (MISVD). Follow-up information regarding survival and cardiac events such as angina, reinfarction and heart failure was collected and prognostic factors identified.

RESULTS

Compared with the MISVD group, MINC patients had a lower prevalence of hypercholesterolemia and ST elevation. Hypercoagulopathy, collagen tissue disorder, cocaine abuse and Takotsubo cardiomyopathy were identified etiologies in some MINC patients. During follow-up, patients with MINC were less likely to sustain reinfarction (log-rank P<0.001) and cardiovascular death (log-rank P=0.04) on Kaplan-Meier survival analysis. Recurrence of angina and heart failure were the most prevalent cardiac events in the MINC group. Cox proportional multivariate regression analysis identified left ventricular ejection fraction as an independent predictor of cardiac events in the MINC cohort.

CONCLUSION

MINC is associated with lower mortality and morbidity compared with infarction in the setting of single vessel disease. Left ventricular function is an independent predictor of poor outcome.

Transient left ventricular apical ballooning after physical exercise

A 43-year-old woman with mild hypertension and type-2 diabetes mellitus was presented to the coronary care unit because of ongoing chest pain and associated dyspnea after physical exercise. On arrival, her ECG disclosed ST-segment elevations in the precordial leads. The emergent cardiac catheterization failed to demonstrate coronary artery disease. The prompt performed transthoracic echocardiogram demonstrated systolic dysfunction with apical ballooning. Akinetic segments were irrespective of coronary artery anatomy. Laboratory tests revealed only slightly elevated cardiac enzymes: we observed a significant discrepancy between the extent of akinesis and the minimal increase in cardiac necroenzymes. The patient was medically managed and discharged in stable condition, with follow-up at 4 weeks demonstrating nearly total recovery of cardiac function and total resolution of wall motion disorder. Her clinical presentation is consistent with that of tako-tsubo cardiomyopathy, a syndrome that is characterized by transient apical regional wall motion abnormalities in the absence of epicardial coronary artery disease. Main precipitating factor is thought to be the cathecolamin excess due to emotional or physical stress, subarachnoid heamorrhage, phaeochromocytoma or cocaine use. The authors report the first physical exercise induced tako-tsubo syndrome in the Hungarian medical literature.

A rare case of tako-tsubo cardiomyopathy with variable forms of left ventricular dysfunction: a new entity

We report a rare case of an 83-year-old woman with tako-tsubo cardiomyopathy, who presented with variable forms of left ventricular dysfunction during her clinical course. The distribution regional wall-motion abnormalities of the left ventricle on echocardiography had changed from a mid-ventricular ballooning type to the apical ballooning type 3 days from the onset. We suggest that these findings may indicate a new or variant entity of tako-tsubo cardiomyopathy.

A case of takotsubo cardiomyopathy after surgery for common bile duct stones

Takotsubo cardiomyopathy (TC) is a rare reversible circulatory syndrome often detected in elderly patients after general surgery. We report the case of an 85-year-old woman who was admitted for obstructive jaundice and underwent ERCP and ENBD before operation. She finally underwent cholecystectomy and choledocholithotomy with the diagnosis of gallbladder and common bile duct stones. In the evening just after the operation, without symptoms of cardiac failure, her ECG suddenly exhibited abnormal ST-T elevation in leads II, III, and V2-V6, though neither CPK(MB) nor troponin T was elevated. Echocardiogram demonstrated basal hyperkinesis and apical dyskinesis, suggesting TC. Conservative treatment enabled recovery, ECG was normalized in a month, and the postoperative course was satisfactory. The stress on her during treatment might have been a cause of this unique cardiomyopathy, and it should be recalled that TC is a potential complication of hepato-biliary-pancreatic surgery.

Noninvasive detection of Takotsubo [corrected] cardiomyopathy using multi-detector row computed tomography

We present a 60-year-old woman with chest pain preceded by emotional stress. Trans-thoracic echocardiography demonstrated localized left ventricular hypokinesis around the apical area. Multi-detector row computed tomography (MDCT) revealed no significant stenosis in the coronary arteries, which comfirmed Takotsubo-like cardiomyopathy. We show here the usefulness of MDCT for the noninvasive differentiation of Takotsubo cardiomyopathy from acute coronary syndrome.

Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction

Apical ballooning syndrome (ABS) is a unique reversible cardiomyopathy that is frequently precipitated by a stressful event and has a clinical presentation that is indistinguishable from a myocardial infarction. We review the best evidence regarding the pathophysiology, clinical features, investigation, and management of ABS. The incidence of ABS is estimated to be 1% to 2% of patients presenting with an acute myocardial infarction. The pathophysiology remains unknown, but catecholamine mediated myocardial stunning is the most favored explanation. Chest pain and dyspnea are the typical presenting symptoms. Transient ST elevation may be present on the electrocardiogram, and a small rise in cardiac troponin T is invariable. Typically, there is hypokinesis or akinesis of the mid and apical segments of the left ventricle with sparing of the basal systolic function without obstructive coronary lesions. Supportive treatment leads to spontaneous rapid recovery in nearly all patients. The prognosis is excellent, and a recurrence occurs in <10% of patients. Apical ballooning syndrome should be included in the differential diagnosis of patients with an apparent acute coronary syndrome with left ventricular regional wall motion abnormality and absence of obstructive coronary artery disease, especially in the setting of a stressful trigger.

MRI for the diagnosis of left ventricular apical ballooning syndrome (LVABS)

To compare MRI findings of left ventricular apical ballooning syndrome (LVABS) with those of acute myocardial infarction (AMI). Fifteen patients with a LVABS (group 1) and 25 patients with an AMI (group 2) were explored by MRI within 24 h after admission. Comparison of both groups for the number and location of myocardial segments with abnormal wall motion and abnormal perfusion or delayed enhancement was performed. The number of involved segments was higher in group 1 than in group 2 (p<0.001). In group 1, segments with abnormal wall motion were distributed in more than one vascular territory in all patients and confined to the medial, distal, and apical regions of the left ventricle. Subendocardial hypoenhancement was observed in 16/25 patients (64%) in group 2 and in none of group 1 (p<0.001). All patients in group 2 demonstrated delayed-enhancement abnormalities in a vascular distribution, whereas none in group 1 presented this abnormality (p<0.001). Diffusely distributed segmental wall-motion abnormalities and absence of first-pass perfusion hypoenhancement and of delayed enhancement at MRI help to differentiate LVABS from AMI. In the acute phase or in some difficult cases, cardiac MRI should become routine to confirm the diagnosis of LVABS.

Stress (Takotsubo) cardiomyopathy--a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning

Stress cardiomyopathy, also referred to as Takotsubo cardiomyopathy, is an increasingly recognized clinical syndrome characterized by acute reversible apical ventricular dysfunction. We hypothesize that stress cardiomyopathy is a form of myocardial stunning, but with different cellular mechanisms to those seen during transient episodes of ischemia secondary to coronary stenoses. In this syndrome, we believe that high levels of circulating epinephrine trigger a switch in intracellular signal trafficking in ventricular cardiomyocytes, from G(s) protein to G(i) protein signaling via the beta(2)-adrenoceptor. Although this switch to beta(2)-adrenoceptor-G(i) protein signaling protects against the proapoptotic effects of intense activation of beta(1)-adrenoceptors, it is also negatively inotropic. This effect is greatest at the apical myocardium, in which the beta-adrenoceptor density is greatest. Our hypothesis has implications for the use of drugs or devices in the treatment of patients with stress cardiomyopathy.

Neurogenic stunned myocardium associated with status epileptics and postictal catecholamine surge

A 75-year-old woman developed left ventricular apical ballooning, shortly after recovering from status epileptics. Plasma noradrenaline and adrenaline levels were 2.05 ng/ml and 0.48 ng/ml, respectively. Endomyocardial biopsy disclosed patchy areas of interstitial myocardial fibrosis, atrophy and vacuolization of cardiac myocytes, and some disappearance of myocyte nuclei. Follow-up echocardiography showed that the left ventricular apical ballooning was restored to normal within 25 days. These findings are compatible with neurogenic stunned myocardium. It is important to recognize that patients suffering from intractable seizures may harbor a risk of postictal catecholamine surge and catecholamine-induced myocardial dysfunction.

Recurrent takotsubo cardiomyopathy within a short span of time in a patient with hereditary motor and sensory neuropathy

A 53-year-old woman with hereditary motor and sensory neuropathy was admitted to our hospital with congestive heart failure, followed by cardiogenic shock and acute renal failure. The patient's neuropathy was a rare entity documented first in a local area of Okinawa, Japan. Intensive supportive therapy was performed and the patient recovered within 4 weeks. Echocardiography revealed takotsubo-type left ventricular wall motion abnormality at onset. During hospitalization, restoration and recurrence of apical ballooning were observed at shorter intervals of days. The unique left ventricular wall motion abnormality of takotsubo cardiomyopathy is possibly a dynamically repetitive phenomenon. Serial echocardiographic studies are necessary so as not to miss recurrences within short intervals.

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a disease in which patients present with signs and symptoms mimicking an acute coronary syndrome and, thus, undergo cardiac catheterization. At the time of catheterization, however, no critical coronary lesions are found. Most of these patients have a characteristic left ventriculogram and recent history of a preceding stressor. While the acute phase of the illness can lead to ventricular tachyarrhythmias and possibly even death, a key feature of this syndrome in the majority of patients is its generally benign course and reversibility in myocardial dysfunction over a period of days to weeks. The pathophysiology of Takotsubo cardiomyopathy remains unclear. Optimal long-term medical therapy has not been well established at this time, since the etiology of the disease process remains a source of debate.

Takotsubo cardiomyopathy: An under-recognized myocardial syndrome

Takotsubo cardiomyopathy is characterized by reversible left ventricular dysfunction with apical ballooning and is triggered by marked psychological or physiological stress in the absence of significant epicardial coronary artery disease. Clinically, this unique myocardial syndrome mimics acute myocardial infarction, and it has been considered to be a rare entity with a good prognosis. The literature on takotsubo cardiomyopathy is limited by selection bias and patient heterogeneity, but recent data suggest the syndrome is more prevalent, e.g., in critically ill, non-cardiac patients. Prompt diagnosis and aggressive therapy are essential for a rapid recovery. Clinicians should increase their awareness of this syndrome and more research should be carried out on the epidemiology, pathophysiology, and treatment of takotsubo cardiomyopathy.