Reverse Takotsubo-Kardiomyopathie – eine lebensbedrohliche Erkrankung: Erfolgreiche Reanimation einer 31 Jahre alten Frau mit kardiogenem Schock nach Zahnarztbesuch

When a Tooth Pulls the Heart Strings: Takotsubo Cardiomyopathy Post-dental Extraction

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, is a temporary left ventricular dysfunction caused by a catecholamine surge under severe stress. It's characterized by chest pain, non-specific ECG changes, and left ventricular apical ballooning observed during catheterization. We present a case of a 59-year-old postmenopausal female with a past medical history of asthma who arrived at the ED complaining of chest pain following dental extraction. The patient's abnormal ECG findings and elevated cardiac enzymes required cardiac catheterization, which revealed normal coronary vasculature but demonstrated left ventricular apical ballooning. Transthoracic echocardiogram (TTE) showed septal left ventricular hypertrophy, decreased ejection fraction (EF), and akinetic segments consistent with takotsubo cardiomyopathy. Secondary takotsubo cardiomyopathy induced by stress in the setting of dental procedures like a tooth extraction for a periapical dental abscess is rarely described in the literature. Our case serves as a reminder of the potential for stress-induced cardiomyopathy in postmenopausal women, especially those with undiagnosed underlying anxiety disorders, even following minimally invasive procedures.

Takotsubo syndrome after a minimally invasive tooth extraction in a patient without dental phobia: A case report

Takotsubo syndrome (TTS) is a rare, stress-induced acute cardiac disorder. Its precipitating factors include emotionally or physically stressful events and exogenous and endogenous adrenaline. In this report, we describe a case of atypical TTS in a 73-year-old woman who reported no dental fear and required acute cardiac care in an outpatient setting. She underwent routine extraction of an upper left premolar under local anesthesia. She reported heart palpitations after the injection, and the procedure was completed in 15 min. After presenting symptoms of sweating, pale skin, vomiting, low blood pressure, and ST-segment elevation, cardiologists ordered echocardiography, coronary angiography, and ventriculography. Upon receiving a TTS diagnosis, the patient was hospitalized and administered an intra-aortic balloon pump and beta-blocker. Her symptoms resolved, and she was discharged with no sequelae. We found no precipitating factors in the progression of TTS in this case, which suggests that TTS can develop in the absence of precipitating factors. All general dentists and oral surgeons should recognize the possible risk of TTS, even during minimally invasive dental procedures, such as routine extractions in patients without dental phobia.

Impact of intra-aortic balloon counterpulsation on all-cause mortality among patients with Takotsubo syndrome complicated by cardiogenic shock: results from the German-Italian-Spanish (GEIST) registry

Aims

Takotsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction and can be complicated by cardiogenic shock (CS). However, few data are available on optimal care in TTS complicated by CS. Aim of this study was to evaluate short- and long-term impact of intra-aortic balloon pumping (IABP) on mortality in this setting.

Methods and results

In a multi-centre, international registry on TTS, 2248 consecutive patients were enrolled from 38 centres from Germany, Italy, and Spain. Of the 2248 patients, 212 (9.4%) experienced CS. Patients with CS had a higher prevalence of diabetes (27% vs. 19%), male sex (25% vs. 10%), and right ventricular involvement (10% vs. 5%) (P < 0.01 in all cases). Forty-three patients with CS (20% of 212) received IABP within 8 h (interquartile range 4-18) after admission. No differences in terms of age, gender, cardiovascular risk factors, and admission left ventricular ejection fraction were found among patients with and without IABP. There were no significant differences in terms of 30-day mortality (16% vs. 17%, P = 0.98), length of hospitalization (18.9 vs. 16.7 days, P = 0.51), and need of invasive ventilation (35% vs. 41%, P = 0.60) among two groups: 30-day survival was not significantly different even after propensity score adjustment (log-rank P = 0.73). At 42-month follow-up, overall mortality in patients with CS and TTS was 35%, not significantly different between patients receiving IABP and not (37% vs. 35%, P = 0.72).

Conclusions

In a large multi-centre observational registry, the use of IABP was not associated with lower mortality rates at short- and long-term follow-up in patients with TTS and CS.

Takotsubo Syndrome in New Zealand: Current Knowledge and Future Challenges

Takotsubo syndrome (TS), also known as apical ballooning syndrome is a transient stress-related cardiomyopathy characterised by acute but reversible left ventricular dysfunction. The condition tends to occur in postmenopausal women after a stressful event. At presentation TS typically mimics acute myocardial infarction (MI) and the incidence of TS has been increasing worldwide. This is likely a consequence of an improved awareness of the existence of this syndrome and easier access to early echocardiography and coronary angiography. However, its aetiology remains poorly understood and it is probably still underdiagnosed. Similar to other countries. TS is being increasingly recognised in New Zealand. In this review, we discuss the demographics, clinical features and outcomes of patients with TS in New Zealand. Doing so informs us not only of the pattern of disease in New Zealand but it also provides insights into the condition itself. This article is protected by copyright. All rights reserved.

Stress cardiomyopathy: Medical studies and extensive review

Stress cardiomyopathy (SC) was first reported in the year 1983. It is narrated as critical but quite commutative left ventricular (LV) malfunction mostly caused by poignant or psychological disorder. Numerous variations of SC have been described as well as reverse stress cardiomyopathy (rSC) which is an adaptation identified by the decreased muscle movement related with hyperkinesis that reconciles impetuously. The signature of rSC is a medical demonstration alike to syndrome by an acute coronary, with no obvious difficult coronary artery disease. The occurrence of SC is approximated to be 4% of all victims conferring with gleaned syndrome by acute coronary. The portion of victims conferring with the rSC transfiguration out of all SC patients has been inconstant, varying from 1 to 24%. Reverse stress cardiomyopathy cases are found to be common with young people, less decrease in left ventricular ejection fraction (LVEF) and more neurological disease compared to the SC. While the correct phenomenon of rSC is undetermined, postulated methods comprises of coronary microvasculature impairment, coronary artery spasm, and estrogen deficiency. Patients with rSC typically suffer with chest pain after an emotional or Psychological stressful event. The rSC can also be happened by general anesthesia, or neurological conditions. The diagnosis of rSC demands the presence of new electrocardiogram (EKG) abnormalities or elevated cardiac troponin, and absence of obstructive coronary disease, pheochromocytoma, or myocarditis. The consideration of rSC is quite analogous to that of SC, which is predominantly supportive with the treatment of complications. The recrudescence rate of rSC is around 12%. The most frequent complications of rSC include pericardial effusions, and development of LV thrombi.

Reverse Takotsubo cardiomyopathy: a comprehensive review

Takotsubo cardiomyopathy (TTC) was first described in Japan in the 1980s. It is described as an acute but often reversible left ventricular (LV) dysfunction mainly triggered by emotional or physical stress. Multiple variants of TTC have been reported including reverse Takotsubo cardiomyopathy (rTTC) which is a variant characterized by the basal akinesis/hypokinesis associated with apical hyperkinesis that resolves spontaneously. The hallmark of rTTC is a clinical presentation similar to an acute coronary syndrome (ACS), with no evident obstructive coronary artery disease. The incidence of TTC is estimated to be 2% of all troponin-positive patients presenting with suspected ACS. The proportion of patients presenting with the rTTC variant out of all TTC patients in published literature has been variable, ranging from 1-23%. Reverse Takotsubo has been associated with younger age, less decrease in left ventricular ejection fraction (LVEF), and more neurological disease compared to the TTC. While the exact mechanism of rTTC is unknown, hypothesized mechanisms include catecholamine cardiotoxicity, coronary artery spasm, coronary microvasculature impairment, and estrogen deficiency. Patients with rTTC typically present with chest pain and/or dyspnea after an emotional or physically stressful event. rTTC can also be triggered by intracranial hemorrhage, general anesthesia, or neurological conditions. Diagnosis of rTTC requires the presence of LV basal hypokinesis/akinesis, new electrocardiogram (EKG) abnormalities or elevated cardiac troponin, and absence of obstructive coronary disease, pheochromocytoma, or myocarditis. Management of rTTC is similar to that of TTC, which is predominantly supportive with the treatment of complications. The recurrence rate of rTTC is around 10%. The most common complications of rTTC include myocarditis, pleural and pericardial effusions, and development of LV thrombi. The best predictors of mortality include decreased LVEF, development of atrial fibrillation, and neurologic disease.

Takotsubo Syndrome After Surgical and Nonsurgical Oral and Maxillofacial Events: Review of Published Cases

PURPOSE

Takotsubo syndrome (TS) is an acute and potentially serious cardiac disorder that is often attributed to an exuberant catecholaminergic response to a severely physical or emotional event. As there is a paucity of information in the dental literature on TS, this article will provide an overview of this uncommon syndrome, including clinical presentation, demographic characteristics, etiopathogenesis, diagnosis, management, and recovery, particularly emphasizing its occurrence with oral and maxillofacial procedures.

PATIENTS AND METHODS

A PubMed search with the keyword "takotsubo" for publications from 1991 through May 2018 yielded 3,778 articles. Case reports and case series of TS associated with surgical and nonsurgical procedures in the oral and maxillofacial region were reviewed. Other cases were identified using a defined search strategy.

RESULTS

The literature search identified 28 documented episodes of TS that occurred with head and neck surgical procedures, mostly sinus, carotid, nasal, and cancer reconstruction surgical procedures, and notably, 3 cases occurred concurrently with dental extractions. In all of the featured patients, some degree of cardiovascular impairment developed and phenotypic overlap with acute occlusive coronary disease was shown. Most patients recovered within 2 weeks, and recovery in the remainder extended up to 3 months.

CONCLUSIONS

On rare occasions, TS has been reported in association with oral and maxillofacial procedures. As stress appears to be a precipitating factor in the development of TS, perioperative efforts should be instituted to reduce an adrenergic cascade.

[Treatment of an uncommon case of a cardiogenic shock : Simultaneous use of a VA-ECMO and an Impella-CP®]

We report the case of a 48-year old woman where probably the intramuscular administration of glucocorticoids by an orthopedist induced a pheochromocytoma crisis. The development of a cardiogenic shock with a cardiac arrest made the use of a venoarterial extra corporeal membrane oxygenation (VA-ECMO, Cardiohelp®, Maquet, Rastatt) necessary. To treat a pulmonary edema under VA-ECMO an Impella-CP® (Abiomed, Aachen) was implanted. A coronary angiography, endomyocardial biopsies and a computer tomography were performed. Finally a 7 cm × 5 cm tumor mass in the left adrenal medulla was detected. The blood values presented high levels of catecholamines. The total results of the examinations led us to the final diagnosis of a pheochromocytoma which was finally surgical removed.

Cardiogenic Shock due to Psychosis-Induced Inverted Takotsubo Cardiomyopathy Bridged-to-Recovery with a Percutaneous Left Ventricular Assist Device

Inverted Takotsubo cardiomyopathy, a less common variant in the spectrum of stress-induced cardiomyopathy, is increasingly being reported. This report describes an acute psychiatric illness leading to the onset of this syndrome. The patient presented here developed cardiogenic shock but successfully recovered with the use of a percutaneous left ventricular assist device.

[Inverted takotsubo cardiomyopathy due to subarachnoid haemorrhage]

We present a case of a 34-year-old woman with cardiogenic shock after successful resuscitation. In the medical history migraine was known. Emergency echocardiography demonstrated left ventricular dysfunction with hypokinetic basal and midventricular segments and hyperkinetic apex. Cerebral computed tomography suggested a massive subarachnoid haemorrhage (SAH) with transtentorial herniation, so that taking into account the clinical history (severe headache) the diagnosis of a SAH-associated inverted takotsubo cardiomyopathy could be made. In the case of subarachnoid haemorrhage it should be noted that extracerebral organ dysfunction, e.g. inverted takotsubo cardiomyopathy, frequently occurs.

Natural history of cardiac arrest in patients with takotsubo cardiomyopathy

Cardiac arrest (CA) is relatively rare but lethal complication of takotsubo cardiomyopathy (TTC). In most instances, patients are diagnosed with TTC after CA, making it difficult to distinguish if TTC is the precipitant or the consequence of the index event. In this systematic review, patient-level data were obtained to seek out the characteristics of patients in whom the underlying cause of CA is TTC. A comprehensive search of 4 major databases (Embase, Ovid MEDLINE, PubMed, and Google Scholar) was performed from their inception to the last week of September 2014. Of 186 citations, 62 case studies were included in the analysis, providing patient-level data on 77 patients. In 60 patients (78%), the diagnosis of TTC was made after CA. Patients presenting with CA were younger (mean age 49.5 ± 16 vs 64.9 ± 11 years, p <0.0001) and had relatively shorter corrected QT interval (mean 530 ± 101 vs 616 ± 140 ms) on electrocardiography. TTC-related hypotension was the major cause of CA in the acute phase, while a long corrected QT interval triggered CA in the subacute (24- to 72-hour) phase. In 11 patients, CA was not directly instigated by TTC despite a left ventricular appearance matching TTC. In conclusion, in TTC, CA typically develops within the first 3 days of presentation and is the result of long corrected QT interval-induced polymorphic ventricular tachycardia. Secondary TTC, in which patients present with typical left ventricular features after CA, likely represents a distinct cohort in which identifiable inheritable arrhythmias or structural heart disease should be sought.

Coronary vasospasm is an unlikely cause of Takotsubo syndrome, although we should keep an open mind

This viewpoint pertains to the still elusive pathophysiology of the Takotsubo syndrome (TTS), maintaining the position that this affliction is not the result of coronary vasospasm (CV) involving one or more coronary arteries. Although CV has been rarely encountered in the acute stage of TTS, or elicited via provocative testing in the subacute stage of the disease, it does not appear to be the cause of TTS as shown by the bulk of the published relevant literature. The author provides some speculations to explain the spontaneous appearance of CV, or its artificial elicitation, in some patients with TTS. However while we are striving to unravel the pathophysiology of TTS, we should keep an open mind about a possible role for CV in the causation of TTS.