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Izumo M, Akashi YJ. Role of echocardiography for takotsubo cardiomyopathy: clinical and prognostic implications. Cardiovasc Diagn Ther 2018; 8:90-100. [PMID: 29541614 PMCID: PMC5835647 DOI: 10.21037/cdt.2017.07.03] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 06/28/2017] [Indexed: 12/26/2022]
Abstract
Takotsubo cardiomyopathy (TTC) is newly-described secondary cardiomyopathy characterized by transient left ventricular (LV) dysfunction, which is increasingly recognized in the field of cardiology. TTC occurs in approximately 2% of the patients with acute coronary syndrome. Its onset is rare; however, its specific features play a crucial role in diagnosing the chest pain in clinical practice. TTC has generally favorable outcome with rapid recovery of LV function; however, an increasing evidence suggests that it should be regarded as a more serious acute cardiac disorder with a variety of complications. Owing to its widespread availability, even in emergency settings, transthoracic echocardiography plays a key role in the diagnostic assessment of TTC and contributes to an increased number of disease detection and incidence reports in contemporary clinical practice. This review focuses on the role of echocardiography in understanding the clinical prognostic implications in patients with TTC.
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Affiliation(s)
- Masaki Izumo
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yoshihiro J Akashi
- Division of Cardiology, Department of Internal Medicine, St. Marianna University School of Medicine, Kawasaki, Japan
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52
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Foley ED, Diaz R, Castresana MR. Prolonged circulatory support with an Impella assist device in the management of cardiogenic shock associated with takotsubo syndrome, severe sepsis and acute respiratory distress syndrome. SAGE Open Med Case Rep 2017; 5:2050313X17741013. [PMID: 29276594 PMCID: PMC5734429 DOI: 10.1177/2050313x17741013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2017] [Accepted: 10/16/2017] [Indexed: 01/20/2023] Open
Abstract
Severe sepsis has been known to trigger for takotsubo syndrome which is associated with profound physical or emotional stress. Severe sepsis is also associated with sepsis-induced cardiomyopathy, a reversible myocardial depression. We report a case in which a patient with takotsubo syndrome, cardiogenic shock, severe sepsis, and adult respiratory distress syndrome was managed with an Impella Cardiac Power circulatory support device for 108 h (4.5 days) because of sustained hemodynamic compromise. To the best of our knowledge, this represents the longest reported use of the Impella Cardiac Power device for the management of cardiogenic shock in a patient with takotsubo syndrome and severe sepsis. This report also highlights the importance of considering a ventricular assist device in the management of takotsubo syndrome cardiogenic shock with severe sepsis which is unresponsive to maximal medical therapy.
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Affiliation(s)
- Edward D Foley
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Ricardo Diaz
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
| | - Manuel R Castresana
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology and Perioperative Medicine, Medical College of Georgia, Augusta University, Augusta, GA, USA
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53
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Casavecchia G, Zicchino S, Gravina M, Maulucci G, Manuppelli V, Tarantino N, Ruggiero A, Russo D, Santoro F, Macarini L, Biase MD, Brunetti ND. Fast ‘wandering’ Takotsubo syndrome: atypical mixed evolution from apical to mid-ventricular ballooning. Future Cardiol 2017; 13:529-532. [DOI: 10.2217/fca-2017-0018] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
We report the case of a 53-year-old woman admitted for typical chest pain and a diagnosis of Takotsubo syndrome (TTS). Initial echocardiographic presentation was characterized by apical and mid-ventricular akinesis and basal hyper-kinesis. Unexpectedly, later after admission, echocardiography showed recovered apical akinesis with an apparent ‘migration’ of systolic dysfunction to mid-ventricular segment and hyper-kinesis of apical and basal segments. One week after admission, left ventricular contractility completely recovered and cardiac magnetic resonance imaging did not show signs of subendocardial late-enhancement and myocardial edema. Cases of TTS may therefore occasionally rapidly ‘wander’ within left ventricular segments, raising doubts over the so far used classification of left ventricular patterns of ballooning in subjects with TTS (typical/atypical). Apparently, different patterns can rapidly evolve into each other. The absence of late-enhancement at cardiac magnetic resonance imaging could hypothetically identify rapidly ‘wandering’ cases.
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Affiliation(s)
| | | | - Matteo Gravina
- Cardiology Department, University of Foggia, Foggia, Italy
| | | | | | | | | | - Dolores Russo
- Cardiology Department, University of Foggia, Foggia, Italy
| | | | - Luca Macarini
- Cardiology Department, University of Foggia, Foggia, Italy
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Guaricci AI, Musci RL, Pollice P, Marangelli V, Pepe M, Masi F, Nacci F, Zanna D, Favale S. A concealed case of takotsubo syndrome as consequence of ab ingestis episode in a revascularized patient. J Cardiovasc Med (Hagerstown) 2017; 18:985-988. [PMID: 28914662 DOI: 10.2459/jcm.0000000000000569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Andrea I Guaricci
- Institute of Cardiovascular Disease, Department of Emergency and Organ Transplantation, University Hospital Policlinico of Bari, Bari, Italy
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55
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Gue YX, Bhandari SS, Ahamed M. An uncommon manifestation of shock: Takotsubo syndrome. Echo Res Pract 2017; 4:K41-K45. [PMID: 28916516 PMCID: PMC5633058 DOI: 10.1530/erp-17-0040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Accepted: 09/11/2017] [Indexed: 11/25/2022] Open
Abstract
76-year-old female presented following an episode of collapse. She was hypotensive with the paramedics and remained refractory despite fluid resuscitation. Her initial baseline tests revealed an elevated troponin; she subsequently underwent a coronary angiogram that showed mild coronary artery disease. Left ventriculogram was performed, which showed abnormal mid-wall ballooning and severely impaired systolic function, characteristic of Takotsubo syndrome. Echocardiogram confirmed the presence of diagnosis and presence of left ventricular outflow tract obstruction with high gradient. She was initiated on medical heart failure therapy and improved. Follow-up investigations after 2 months showed complete resolution of systolic dysfunction and symptoms.
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Affiliation(s)
- Ying X Gue
- Department of Cardiology, Royal Derby Hospital, Derby Hospital NHS Foundation Trust, Derby, UK
| | - Sanjay S Bhandari
- Department of Cardiology, Royal Derby Hospital, Derby Hospital NHS Foundation Trust, Derby, UK
| | - Mubarak Ahamed
- Department of Cardiology, Royal Derby Hospital, Derby Hospital NHS Foundation Trust, Derby, UK
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56
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Parodi G, Scudiero F, Citro R, Silverio A, Bellandi B, Zito C, Antonini-Canterin F, Rigo F, Zocchi C, Bossone E, Salerno-Uriarte J, Piscione F, Mario CD. Risk Stratification Using the CHA 2DS 2-VASc Score in Takotsubo Syndrome: Data From the Takotsubo Italian Network. J Am Heart Assoc 2017; 6:JAHA.117.006065. [PMID: 28912212 PMCID: PMC5634272 DOI: 10.1161/jaha.117.006065] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The CHA2DS2‐VASc score predicts stroke in patients with atrial fibrillation and has been reported to have a prognostic role even in acute coronary syndrome patients. The Takotsubo syndrome is a condition that mimics acute coronary syndrome and may present several complications including stroke. We sought to assess the ability of CHA2DS2‐VASc score to predict adverse events in Takotsubo syndrome patients. Methods and Results Overall, 371 Takotsubo syndrome patients were enrolled in a prospective registry. Patients were divided into 3 groups according to the CHA2DS2‐VASc score: Group A (≤1), B (2–3), and C (≥4). The median CHA2DS2‐VASc score was 3 (interquartile range: 2–4). Overall, 9%, 42%, and 49% were included in Group A, B, and C, respectively. Follow‐up length was 26±20 months. The mortality rate was 6%, 7%, and 17% in Group A, B, and C, respectively (P=0.011). The stroke rate was 3% and not different among the 3 groups. Estimated major adverse cardiac and cerebrovascular events (the composite of death, myocardial infarction, and stroke) rates in the 3 groups were 6%, 9%, and 17% in Group A, B, and C, respectively (P=0.033). The CHA2DS2‐VASc score resulted as a predictor of major adverse cardiac and cerebrovascular events (odds ratio 2.1, 95% confidence interval, 1.2–3.6; P=0.01) and all‐cause mortality (odds ratio 1.5, 95% confidence interval, 1.2–1.9; P=0.001). Conclusions In Takotsubo syndrome, the CHA2DS2‐VASc score allows prediction of cardiovascular events and mortality at long‐term follow‐up.
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Affiliation(s)
- Guido Parodi
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy .,Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | - Fernando Scudiero
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Rodolfo Citro
- University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Angelo Silverio
- University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Benedetta Bellandi
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Concetta Zito
- Department of Clinical and Experimental Medicine, University of Messina, Italy
| | | | - Fausto Rigo
- Department of Cardiology, Dell'Angelo Hospital, Mestre, Italy
| | - Chiara Zocchi
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Eduardo Bossone
- University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Jorge Salerno-Uriarte
- Department of Cardiology, University of Insubria, Ospedale di Circolo and Fond. Macchi, Varese, Italy
| | - Federico Piscione
- University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Carlo Di Mario
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
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Hydrogen sulfide attenuates cardiac injury in takotsubo cardiomyopathy by alleviating oxidative stress. Nitric Oxide 2017; 67:10-25. [PMID: 28450188 DOI: 10.1016/j.niox.2017.04.010] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2017] [Revised: 03/23/2017] [Accepted: 04/21/2017] [Indexed: 12/16/2022]
Abstract
Takotsubo cardiomyopathy (TCM) is characterized by transient left ventricular apical ballooning with the absence of coronary occlusion, which is an acute cardiac syndrome with substantial morbidity and mortality. It was reported that reduced endogenous hydrogen sulfide (H2S) levels may be related to various heart diseases. The present study investigated the mechanism by which H2S administration modulates and protects cardiac function in TCM rats. In order to establish a TCM model, Sprague Dawley (SD) rats were injected with a single dose of β-adrenergic agonist isoprenaline (ISO). We found that ISO induced cardiac dysfunction, which was characterized by a significant decrease in left ventricular systolic pressure (LVSP), maximum contraction velocity (+dp/dtmax), maximum relaxation velocity (-dp/dtmax) and increased left ventricular end-diastolic pressure (LVEDP). Accordingly, we found that plasma and heart tissue H2S levels in TCM rats decreased significantly, and cardiac cystathionine γ-lyase (CSE) and 3-mercaptopyruvate sulfurtransferase (3-MST) expression were lower. Moreover, cardiac dysfunction in TCM was associated with oxidative stress response and reactive oxygen species (ROS) formation. NADPH Oxidase 4 (NOX4) and p67 protein expressions significantly increased in TCM cardiac tissues. In addition, Sodium hydrosulfide (NaHS) ameliorated ISO-induced cardiac dysfunction and reversed ISO-induced oxidative stress. This study revealed that H2S exerted cardioprotective effects by reducing NADPH oxidase, which reduced ROS formation and prevented oxidative stress. Our study provided novel evidence that H2S is protective in myocardial dysfunction in TCM rats and could be a therapeutic target for alleviating β-adrenergic system overstimulation-induced cardiovascular dysfunction.
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58
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Citro R, Pontone G, Pace L, Zito C, Silverio A, Bossone E, Piscione F. Contemporary Imaging in Takotsubo Syndrome. Heart Fail Clin 2017; 12:559-75. [PMID: 27638026 DOI: 10.1016/j.hfc.2016.06.005] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Transthoracic echocardiography is the first-line imaging modality for evaluating patients with Takotsubo syndrome (TTS). Beyond diagnosis, TTE enables detection of peculiar complications and is useful for risk stratification and management of patients with cardiogenic shock. Cardiac magnetic resonance can be used to detect myocardial edema typically associated with TTS and is helpful in the differential diagnosis with other disease states. Coronary computed tomography angiography can be performed as an alternative to coronary angiography to confirm coronary artery patency. Molecular imaging is a promising approach for identifying patients at increased risk of recurrence.
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Affiliation(s)
- Rodolfo Citro
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Heart Tower Room 810, Largo Città di Ippocrate, Salerno 84131, Italy.
| | - Gianluca Pontone
- Centro Cardiolgico Monzino, IRCCS, Via Carlo Parea 4, 20138, Milan, Italy
| | - Leonardo Pace
- Department of Medicine and Surgery, Schola Medica Salernitana, University of Salerno, Via Salvador Allende, 84081 Baronissi (Salerno), Italy
| | - Concetta Zito
- Cardiology, Department of Clinical and Experimental Medicine, University of Messina, Piazza Pugliatti 1, 98122 Messina, Italy
| | - Angelo Silverio
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Heart Tower Room 810, Largo Città di Ippocrate, Salerno 84131, Italy
| | - Eduardo Bossone
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Heart Tower Room 810, Largo Città di Ippocrate, Salerno 84131, Italy
| | - Federico Piscione
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona," Heart Tower Room 810, Largo Città di Ippocrate, Salerno 84131, Italy; Department of Medicine and Surgery, Schola Medica Salernitana, University of Salerno, Via Salvador Allende, 84081 Baronissi (Salerno), Italy
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59
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Cai L, Addetia K, Medvedofsky D, Spencer KT. Myocardial strain may be useful in differentiating Takotsubo cardiomyopathy from left anterior descending coronary artery ischemia. Int J Cardiol 2017; 230:359-363. [DOI: 10.1016/j.ijcard.2016.12.104] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2016] [Revised: 12/01/2016] [Accepted: 12/17/2016] [Indexed: 01/25/2023]
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Weiner MM, Asher DI, Augoustides JG, Evans AS, Patel PA, Gutsche JT, Mookadam F, Ramakrishna H. Takotsubo Cardiomyopathy: A Clinical Update for the Cardiovascular Anesthesiologist. J Cardiothorac Vasc Anesth 2017; 31:334-344. [DOI: 10.1053/j.jvca.2016.06.004] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2016] [Indexed: 12/20/2022]
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61
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Citro R, Bellino M, Minichino F, Di Vece D, Ferraioli D, Petta R. Subsequent Safe Pregnancy with Cesarean Delivery in a Patient with a History of Peripartum Takotsubo Syndrome Complicated by Cardiogenic Shock. J Cardiovasc Echogr 2017; 27:114-117. [PMID: 28758066 PMCID: PMC5516443 DOI: 10.4103/jcecho.jcecho_24_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Takotsubo syndrome (TTS) is an acute and reversible heart failure syndrome, usually occurring in females but rarely in the peripartum period. In women with a history of peripartum TTS, it is unclear how to manage subsequent pregnancies. A 39-year-old female with a history of peripartum TTS complicated by cardiogenic shock became pregnant again. She underwent close cardiological follow-up for monitoring left ventricular systolic function and hemodynamic conditions. Epidural anesthesia was preferred to avoid catecholamine surge during cesarean delivery. After a few days of hospitalization, the patient and the newborn were discharged in good health. In our patient with a history of complicated peripartum TTS, close cardiological follow-up, appropriate management therapy, and anesthesia modality allow us to guide safely a new pregnancy.
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Affiliation(s)
- Rodolfo Citro
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Michele Bellino
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Flora Minichino
- Division of Anesthesiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Davide Di Vece
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Donatella Ferraioli
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Raffaele Petta
- Division of Obstetrics and Gynecology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
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Kagiyama N, Okura H, Matsue Y, Tamada T, Imai K, Yamada R, Kume T, Hayashida A, Neishi Y, Yoshida K. Multiple Unfavorable Echocardiographic Findings in Takotsubo Cardiomyopathy Are Associated with Increased In-Hospital Events and Mortality. J Am Soc Echocardiogr 2016; 29:1179-1187. [DOI: 10.1016/j.echo.2016.08.021] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2016] [Indexed: 10/20/2022]
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Glaveckaitė S, Šerpytis P, Pečiūraitė D, Puronaitė R, Valevičienė N. Clinical features and three-year outcomes of Takotsubo (stress) cardiomyopathy: Observational data from one center. Hellenic J Cardiol 2016; 57:428-434. [PMID: 28087310 DOI: 10.1016/j.hjc.2016.11.016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2015] [Accepted: 09/29/2016] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The natural history, management, and outcome of Takotsubo (stress) cardiomyopathy (TTC) is not clear. The aim of this study was to investigate clinical features, define prognostic predictors, and assess the clinical course and outcomes of patients with TTC. METHODS We analyzed 64 patients (52 women) meeting the proposed Mayo Clinic diagnostic criteria for TTC. All patients were treated at Vilnius University Hospital Santariskiu Klinikos from 2001-01-01 to 2014-11-27. Data were collected on the basis of medical records and follow-up data was collected by phone. RESULTS The mean age of analyzed patients was 63.4 ± 14.6 years; the mean follow-up was 2.9 years. More than half of the patients (52%) did not have any clear stressful triggers. During admission, symptoms such as chest pain (64%) and general weakness (45%) were reported more often than other symptoms. Almost all patients (94%) had the classical TTC form; the remaining 6% of patients had "inverted" TTC. The mean left ventricular ejection fraction (LVEF) on admission was 37.7% (± 8.2%). A pseudonormal or restrictive pattern of LV filling, moderate to severe mitral regurgitation (MR), and right ventricular involvement were uncommon in the patients. The in-hospital course showed cardiogenic shock in 23% of the cases, resulting in the death of 5 (8%) patients. We discovered that only peak concentration of troponin I was a significant predictor of in-hospital mortality (HR 1.067, 95%CI 1.022-1.113, p=0.003). At the end of the follow-up period, 45 (87%) women and 8 (67%) men were alive. This makes the overall observed mortality at 3 years approximately 17.2%. Using multivariate analysis, elevation of BNP (HR for increase by 10 ng/l 1.002, 95%CI 1-1.003, p=0.022) and cardiogenic shock on admission (HR 8.696, 95%CI 1.198-63.124, p=0.032) were significant predictors of overall mortality. Other prognostic factors assessed on admission were nonsignificant predictors of overall mortality. CONCLUSIONS Our analysis shows that in-hospital mortality is influenced by the peak concentration of troponin I, and overall mortality is affected by cardiogenic shock and the elevation of BNP during admission. The assessment of troponin I and BNP can help with the prognostication of TTC patients in our daily clinical practice.
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Affiliation(s)
- Sigita Glaveckaitė
- Department of Cardiovascular Medicine, Vilnius University, Lithuania; Centre of Cardiology and Angiology, Vilnius University Hospitals Santariskiu Klinikos, Lithuania
| | - Pranas Šerpytis
- Department of Cardiovascular Medicine, Vilnius University, Lithuania; Centre of Cardiology and Angiology, Vilnius University Hospitals Santariskiu Klinikos, Lithuania
| | | | - Roma Puronaitė
- Department of Cardiovascular Medicine, Vilnius University, Lithuania; Centre of Informatics and Development, Vilnius University Hospitals Santariskiu Klinikos, Lithuania
| | - Nomeda Valevičienė
- Department of Radiology, Nuclear Medicine and Medical Physics, Vilnius University, Lithuania
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Goico A, Chandrasekaran M, Herrera CJ. Novel developments in stress cardiomyopathy: From pathophysiology to prognosis. Int J Cardiol 2016; 223:1053-1058. [DOI: 10.1016/j.ijcard.2016.08.241] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2016] [Revised: 08/09/2016] [Accepted: 08/12/2016] [Indexed: 12/20/2022]
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Padang R, Pellikka PA. The role of stress echocardiography in the evaluation of coronary artery disease and myocardial ischemia in women. J Nucl Cardiol 2016; 23:1023-1035. [PMID: 27457525 DOI: 10.1007/s12350-016-0592-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Accepted: 03/08/2016] [Indexed: 01/06/2023]
Abstract
Considering the unfavorable prognosis of women with ischemic heart disease, an aggressive but safe approach to evaluate women presenting with chest pain is warranted so that coronary artery disease (CAD) can be identified and treated early. Stress echocardiography (SE) has matured into an invaluable technique for the noninvasive detection of obstructive epicardial CAD. Its versatility, accuracy, safety, noninvasiveness, and lack of radiation exposure make SE an attractive technique to apply to the assessment of women with known or suspected heart disease. This article focuses on the current evidence supporting the role of SE in the assessment of CAD and myocardial ischemia in women.
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Affiliation(s)
- Ratnasari Padang
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA
| | - Patricia A Pellikka
- Division of Cardiovascular Ultrasound, Department of Cardiovascular Medicine, Mayo Clinic, 200 First St SW, Rochester, MN, 55905, USA.
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66
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Ventricular Septal Defect from Takotsubo Syndrome. Case Rep Cardiol 2016; 2016:2693062. [PMID: 27563471 PMCID: PMC4987479 DOI: 10.1155/2016/2693062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Revised: 06/25/2016] [Accepted: 07/10/2016] [Indexed: 11/17/2022] Open
Abstract
Takotsubo Syndrome is a transient condition characterized by left ventricular systolic dysfunction with apical akinesis/dyskinesis and ballooning. Although the prognosis with medical management is excellent in most cases, rare cases of serious complications can occur. We present here a case of a 71-year-old woman presenting with acute decompensated heart failure with initial findings consistent with a myocardial infarction, who was found instead to have an acute ventricular septal defect as a complication of Takotsubo Syndrome.
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67
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Mejía-Rentería HD, Núñez-Gil IJ. Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy. World J Cardiol 2016; 8:413-424. [PMID: 27468334 PMCID: PMC4958692 DOI: 10.4330/wjc.v8.i7.413] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 04/30/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.
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68
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Abstract
Great advances have been made in our understanding of Takotsubo syndrome in the past decade, but the aetiology of the condition remains incompletely understood. The most established theory, that catecholamine-mediated myocardial stunning is provoked by emotional or physiological stress, is supported by the presence of supraphysiological levels of plasma catecholamines in patients with Takotsubo syndrome. For this reason, the hyperexcitability of the autonomic nervous system under conditions of physical and emotional stress is often assessed in these patients. Observational studies have indicated that a predisposing influence of chronic or traumatic stress, anxiodepressive disorders, and maladaptive personality traits are linked to the pathogenesis of Takotsubo syndrome. Chronic stress can influence autonomic function through dysregulation of the hypothalamic-pituitary-adrenal axis and contribute to the development of cardiovascular disorders. In this Perspectives article, we discuss the current knowledge of the psychoneuroendocrinological and psychosocial mechanisms underlying the pathophysiology of Takotsubo syndrome.
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Citro R, Bossone E, Parodi G, Rigo F, Nardi F, Provenza G, Zito C, Novo G, Vitale G, Prota C, Silverio A, Vriz O, D’Andrea A, Antonini-Canterin F, Salerno-Uriarte J, Piscione F. Independent Impact of RV Involvement on In-Hospital Outcome of Patients With Takotsubo Syndrome. JACC Cardiovasc Imaging 2016; 9:894-895. [DOI: 10.1016/j.jcmg.2015.06.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2015] [Revised: 06/11/2015] [Accepted: 06/18/2015] [Indexed: 11/25/2022]
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Citro R, Bossone E, Parodi G, Carerj S, Ciampi Q, Provenza G, Zito C, Prota C, Silverio A, Vriz O, D'Andrea A, Galasso G, Baldi C, Rigo F, Piepoli M, Salerno-Uriarte J, Piscione F. Clinical profile and in-hospital outcome of Caucasian patients with takotsubo syndrome and right ventricular involvement. Int J Cardiol 2016; 219:455-61. [PMID: 27387098 DOI: 10.1016/j.ijcard.2016.06.039] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Accepted: 06/12/2016] [Indexed: 01/15/2023]
Abstract
AIM To determine the prevalence, clinical characteristics, in-hospital course and determinants of major adverse events in a cohort of Caucasian patients with Takotsubo syndrome (TTS) and right ventricular involvement (RVi), regardless of left ventricular variant forms. METHODS AND RESULTS The study population consisted of 424 patients (mean age 69.1±11.5years; female 92.2%) with a diagnosis of TTS divided into two groups according to the presence or absence of RVi. RVi patients (n=57; 13.4%) showed a higher prevalence of comorbidities, especially respiratory diseases (p=0.011), and a higher Charlson comorbidity index (CCI; p=0.006) than non-RVi patients. In-hospital major adverse events (acute heart failure, cardiogenic shock and death) occurred more frequently in RVi patients (p<0.001). Heart rate and CCI, along with the echocardiographic parameters of wall motion score index, E/e' ratio, tricuspid annular plane systolic excursion (TAPSE) and systolic pulmonary artery pressure (sPAP) were associated with adverse in-hospital outcome. At multivariate analysis, CCI (HR: 1.871; 95% CI: 1.202-2.912; p=0.006), sPAP (HR: 1.059; 95% CI: 1.016-1.104; p=0.007) and TAPSE (HR: 0.728; 95% CI: 0.619-0.855; p<0.001) were independent correlates of the composite outcome in patients with RVi. CONCLUSION Patients with RVi are characterized by distinct clinical profile and should undergo closely clinical and echocardiographic monitoring. The presence of echocardiographic signs of right ventricular failure along with substantial comorbidities burden identify a cohort at higher risk of in-hospital major adverse cardiovascular events.
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Affiliation(s)
- Rodolfo Citro
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy; Department of Heart Sciences, Circolo Hospital and Macchi Foundation, University of Insubria, Varese, Italy.
| | - Eduardo Bossone
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Guido Parodi
- Division of Cardiology, Careggi Hospital, Florence, Italy
| | - Scipione Carerj
- Division of Cardiology, University of Messina, Messina, Italy
| | - Quirino Ciampi
- Division of Cardiology, Ospedale Fatebenefratelli, Benevento, Italy
| | - Gennaro Provenza
- Division of Cardiology, San Francesco d'Assisi, Oliveto Citra, Salerno, Italy
| | - Concetta Zito
- Division of Cardiology, University of Messina, Messina, Italy
| | - Costantina Prota
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Angelo Silverio
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Olga Vriz
- Cardiology and Emergency Department, San Antonio Hospital, San Daniele del Friuli, Udine, Italy
| | | | - Gennaro Galasso
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Cesare Baldi
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
| | - Fausto Rigo
- Department of Cardiology, Dell'Angelo Hospital, Mestre, Italy
| | - Massimo Piepoli
- Division of Cardiology, Ospedale Guglielmo da Saliceto, Piacenza, Italy
| | - Jorge Salerno-Uriarte
- Department of Heart Sciences, Circolo Hospital and Macchi Foundation, University of Insubria, Varese, Italy
| | - Federico Piscione
- Department of Cardiology, University Hospital "San Giovanni di Dio e Ruggi d'Aragona", Salerno, Italy
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Suzuki T, Lyon A, Saggar R, Heaney LM, Aizawa K, Cittadini A, Mauro C, Citro R, Limongelli G, Ferrara F, Vriz O, Morley-Smith A, Calabrò P, Bossone E. Editor's Choice-Biomarkers of acute cardiovascular and pulmonary diseases. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2016; 5:416-33. [PMID: 27221957 DOI: 10.1177/2048872616652309] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/21/2015] [Accepted: 05/10/2016] [Indexed: 12/27/2022]
Abstract
Acute cardiothoracic and respiratory diseases frequently remain a challenge to diagnose and differentiate in the emergency setting. The main diseases that manifest with chest pain include ischaemic heart disease, myocarditis, acute pericarditis, aortic dissection/rupture and pulmonary embolism (PE). Diseases that primarily present with dyspnoea include heart failure (HF), acute respiratory distress syndrome (ARDS), pneumonia, asthma exacerbations and chronic obstructive pulmonary disease. Pre-test probabilities of clinical findings play a vital part in diagnostic decisions, and the use of a Bayesian approach to these greatly improves the ability to stratify patients more accurately. However, blood tests (biomarkers) are increasingly used to assist in rapid decision-making in the emergency setting in combination with imaging methods such as chest radiograph, ultrasound and increasingly computed tomography, as well as physiological tests such as the electrocardiogram in addition to physical examination. Specific tests for ischaemic heart disease and myocarditis (cardiac troponins), HF (B-type natriuretic peptide (BNP) and N-terminal proBNP (NT-proBNP)), aortic dissection (smooth muscle markers) and PE (D-dimer) have been developed. Surfactant protein-D and interleukin-8 have been developed for ARDS. Additionally, circulating microRNAs have emerged as promising biomarker candidates in cardiovascular disease. With this increasing array of biochemical markers to aid in the diagnosis of chest diseases presenting with chest pain and dyspnoea, we herein review the clinical usefulness of these markers, in particular in differentiating cardiac from pulmonary diseases. A symptom-oriented assessment as necessary for use in the critical setting is described in addition to discussion of individual biomarkers.
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Affiliation(s)
- Toru Suzuki
- Department of Cardiovascular Medicine, University of Tokyo, Japan Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, UK
| | - Alexander Lyon
- National Heart and Lung Institute, Imperial College, UK NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, UK
| | - Rajeev Saggar
- Advanced Lung Disease Institute, Banner Good Samaritan Hospital, USA
| | - Liam M Heaney
- Department of Cardiovascular Sciences, University of Leicester, UK NIHR Leicester Cardiovascular Biomedical Research Unit, Glenfield Hospital, UK
| | - Kenichi Aizawa
- Department of Cardiovascular Medicine, University of Tokyo, Japan
| | - Antonio Cittadini
- Department of Medical Translational Sciences, 'Federico II' University, Italy
| | - Ciro Mauro
- Division of Cardiology, A.O.R.N. 'A. Cardarelli', Italy
| | - Rodolfo Citro
- Heart Department, University Hospital, Salerno, Italy
| | | | | | - Olga Vriz
- Cardiology and Emergency Department, Sant'Antonio Hospital, Italy
| | - Andrew Morley-Smith
- National Heart and Lung Institute, Imperial College, UK NIHR Cardiovascular Biomedical Research Unit, Royal Brompton Hospital, UK
| | - Paolo Calabrò
- Division of Cardiology, Second University of Naples, Italy
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Tanabe Y, Akashi YJ. Improving the understanding of Takotsubo syndrome: consequences of diagnosis and treatment. Expert Rev Cardiovasc Ther 2016; 14:737-48. [DOI: 10.1586/14779072.2016.1149468] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Adrenergic Inhibition with Dexmedetomidine to Treat Stress Cardiomyopathy during Alcohol Withdrawal: A Case Report and Literature Review. Case Rep Crit Care 2016; 2016:9693653. [PMID: 27006838 PMCID: PMC4783539 DOI: 10.1155/2016/9693653] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 01/31/2023] Open
Abstract
Stress (Takotsubo) cardiomyopathy is a form of reversible left ventricular dysfunction with a heightened risk of ventricular arrhythmia thought to be caused by high circulating catecholamines. We report a case of stress cardiomyopathy that developed during severe alcohol withdrawal successfully treated with dexmedetomidine. The case involves a 53-year-old man with a significant history of alcohol abuse who presented to a teaching hospital with new-onset seizures. His symptoms of acute alcohol withdrawal were initially treated with benzodiazepines, but the patient later developed hypotension, and stress cardiomyopathy was suspected based on ECG and echocardiographic findings. Adjunctive treatment with the alpha-2-adrenergic agonist, dexmedetomidine, was initiated to curtail excessive sympathetic outflow of the withdrawal syndrome, thereby targeting the presumed pathophysiology of the cardiomyopathy. Significant clinical improvement was observed within one day of initiation of dexmedetomidine. These findings are consistent with other reports suggesting that sympathetic dysregulation during alcohol withdrawal produces ideal pathobiology for stress cardiomyopathy and leads to ventricular arrhythmogenicity. Stress cardiomyopathy should be recognized as a complication of alcohol withdrawal that significantly increases cardiac-related mortality. By helping to correct autonomic dysregulation of the withdrawal syndrome, dexmedetomidine may be useful in the treatment of stress-induced cardiomyopathy.
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Wu Y, Fan W, Chachula L, Costacurta G, Rohatgi R, Elmi F. Left ventricular outflow track obstruction and mitral valve regurgitation in a patient with takotsubo cardiomyopathy. J Community Hosp Intern Med Perspect 2015; 5:29419. [PMID: 26653691 PMCID: PMC4677590 DOI: 10.3402/jchimp.v5.29419] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Revised: 09/17/2015] [Accepted: 09/22/2015] [Indexed: 01/17/2023] Open
Abstract
Introduction Takotsubo cardiomyopathy (TCM) can be complicated by left ventricular outflow tract (LVOT) obstruction and severe acute mitral regurgitation (MR), leading to hemodynamic instability in an otherwise benign disorder. Despite the severity of these complications, there is a paucity of literature on the matter. Because up to 20–25% of TCM patients develop LVOT obstruction and/or MR, it is important to recognize the clinical manifestations of these complications and to adhere to specific management in order to reduce patient morbidity and mortality. We report the clinical history, imaging, treatment strategy, and clinical outcome of a patient with TCM that was complicated with severe MR and LVOT obstruction. We then discuss the pathophysiology, characteristic imaging, key clinical features, and current treatment strategy for this unique patient population. Case report A postmenopausal woman with no clear risk factor for coronary artery disease (CAD) presented to the emergency department with chest pain after an episode of mental/physical stress. Physical examination revealed MR, mild hypotension, and pulmonary vascular congestion. Her troponins were mildly elevated. Cardiac catheterization excluded obstructive CAD, but revealed severe apical hypokinesia and ballooning. Notably, multiple diagnostic tests revealed the presence of severe acute MR and LVOT obstruction. The patient was diagnosed with TCM complicated by underlying MR and LVOT obstruction, and mild hemodynamic instability. The mechanism of her LVOT and MR was attributed to systolic anterior motion of the mitral valve (SAM), which the transesophageal echocardiogram clearly showed during workup. She was treated with beta-blocker, aspirin, and ACE-I with good outcome. Nitroglycerin and inotropes were discontinued and further avoided. Conclusions Our case illustrated LVOT obstruction and MR associated with underlying SAM in a patient with TCM. LVOT obstruction and MR are severe complications of TCM and may result in heart failure and/or pulmonary edema. Timely and accurate identification of these complications is critical to achieve optimal clinical outcomes in patients with TCM.
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Affiliation(s)
- Yin Wu
- Department of Medicine, Easton Hospital, School of Medicine, Drexel University, Easton, PA, USA
| | - WuQiang Fan
- Department of Medicine, Easton Hospital, School of Medicine, Drexel University, Easton, PA, USA;
| | - Laura Chachula
- Philadelphia College of Osteopathic Medicine, Philadelphia, PA, USA
| | - Gary Costacurta
- Easton Cardiovascular Associates, Cardiovascular Institute, Easton Hospital, School of Medicine, Drexel University, Easton, PA, USA
| | - Rajeev Rohatgi
- Easton Cardiovascular Associates, Cardiovascular Institute, Easton Hospital, School of Medicine, Drexel University, Easton, PA, USA
| | - Farhad Elmi
- Easton Cardiovascular Associates, Cardiovascular Institute, Easton Hospital, School of Medicine, Drexel University, Easton, PA, USA
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Meimoun P, Clerc J, Botoro T, Elmkies F, Martis S, Zemir H, Luycx-Bore A. Systolic anterior motion of the mitral valve in tako-tsubo cardiomyopathy: Still a matter of debate? Ann Cardiol Angeiol (Paris) 2015; 64:385-389. [PMID: 26482629 DOI: 10.1016/j.ancard.2015.09.048] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2015] [Accepted: 09/15/2015] [Indexed: 06/05/2023]
Abstract
We present a case which developed a typical tako-tsubo-like cardiomyopathy (TTC) during dobutamine stress echocardiography (DSE). Its originality is related to several findings, which have never been described simultaneously in the same patient. This 63-year-old woman with normal coronary angiography and no evidence of coronary vasospasm had a biphasic response to DSE, a finding which usually occurs in coronary artery disease. Moreover, the symmetric extensive wall motion abnormalities (WMA) occurred simultaneously with the development of a systolic anterior motion of the mitral valve (SAM) and left ventricular obstruction, and was clinically asymptomatic. Although in TTC the stunning usually occurs for several days, WMA and SAM resolved within few minutes after cessation of dobutamine and administration of a beta-blocker. And finally, exercise echo performed at the same target heart rate few days later did not induce neither a SAM nor WMA, which suggests that left ventricular obstruction could have played a role in the pathogenesis of this case by supply-demand mismatch. Concomitant coronary microvascular dysfunction was also demonstrated by a reduction of the non-invasive coronary flow reserve in the distal part of the left anterior descending artery.
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Affiliation(s)
- P Meimoun
- Department of Cardiology and Intensive Care Unit, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France.
| | - J Clerc
- Department of Cardiology and Intensive Care Unit, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
| | - T Botoro
- Department of Cardiology and Intensive Care Unit, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
| | - F Elmkies
- Department of Cardiology and Intensive Care Unit, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
| | - S Martis
- Department of Cardiology and Intensive Care Unit, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
| | - H Zemir
- Department of Cardiology and Intensive Care Unit, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
| | - A Luycx-Bore
- Department of Cardiology and Intensive Care Unit, centre hospitalier de Compiègne, 8, rue Henri-Adnot, 60200 Compiègne, France
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Takotsubo Cardiomyopathy in the Setting of Tension Pneumothorax. Case Rep Crit Care 2015; 2015:536931. [PMID: 26366307 PMCID: PMC4561098 DOI: 10.1155/2015/536931] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 11/18/2022] Open
Abstract
Background. Takotsubo cardiomyopathy is defined as a transient left ventricular dysfunction, usually accompanied by electrocardiographic changes. The literature documents only two other cases of Takotsubo cardiomyopathy in the latter setting. Methods. A 78-year-old female presented to the ED with severe shortness of breath, hypertension, and tachycardia. On physical exam, heart sounds (S1 and S2) were regular and wheezing was noticed bilaterally. We found laboratory results with a WBC of 20.0 (103/μL), troponin of 16.52 ng/mL, CK-mb of 70.6%, and BNP of 177 pg/mL. The patient was intubated for acute hypoxemic respiratory failure. A chest X-ray revealed a large left-sided tension pneumothorax. Initial echocardiogram showed apical ballooning with a LVEF of 10-15%. A cardiac angiography revealed normal coronary arteries with no coronary disease. After supportive treatment, the patient's condition improved with a subsequent echocardiogram showing a LVEF of 60%. Conclusion. The patient was found to have Takotsubo cardiomyopathy in the setting of a tension pneumothorax. The exact mechanisms of ventricular dysfunction have not been clarified. However, multivessel coronary spasm or catecholamine cardiotoxicity has been suggested to have a causative role. We suggest that, in our patient, left ventricular dysfunction was induced by the latter mechanism related to the stress associated with acute pneumothorax.
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