[Transient left ventricular apical ballooning syndrome or Takotsubo cardiomyopathy. About 11 cases]

[The psychiatrist and the Tako Tsubo]

INTRODUCTION

Stress cardiopathy, also called "Tako Tsubo" is a cardiac pathology linked to an acute coronary syndrome with electrocardiographic signs and an increase in the level of cardiac enzymes, without any abnormality on coronarography. This syndrome is secondary to great physical or mental stress. Mortality and the risk of recurrence are low. However, there is no consensus for treatment or prevention.

CASE REPORT

We report the case of 75-year-old woman presenting recurrent cardiogenic shocks. A symptomatic sinusal dysfunction motivated the introduction of a pacemaker in March 2008. One month later, she was hospitalized for a new cardiogenic shock with left ventricular dysfunction, a 40% ejection fraction, and a third degree mitral insufficiency. Cardiac enzymes were initially elevated. Electrocardiogram showed an ST elevation. The transthoracic echocardiogram revealed a left anterolateral ventriculogram dysfunction, and cardiac catheterization showed healthy coronary arteries. The cardiologist wondered about the existence of an anxiodepressive syndrome. No personal psychiatric background was known. The patient was widowed 3 years earlier. She described herself as a naturally anxious person. She hadn't experienced any recent stressing event. She was not depressed and wasn't taking any psychotropic drug. Her family was caring for her. The next day, the patient had another cardiogenic shock and died a few hours later. Maybe the introduction of the pacemaker occasioned one more stress for this patient…

DISCUSSION

We know that people with a stressing job have probably more chance to suffer a myocardial infarction (the risks are 1.5 or two times greater for them). The prevalence of cardiomyopathy syndrome is 4.9% for women. These women have gone through the menopause, with a history of hypertension and anxiodepressive symptoms. However, we do not find any similar description (behavioural scheme type A) as is shown by the psychosomatic school in cases of patients who have gone through myocardial infarction. We also can question ourselves about the fact that some people can be predisposed to suffer from "Tako Tsubo" cardiomyopathy and about the existence of personality disorders. What then is the role of the psychiatrist with these patients?

Clinical characteristics of tako-tsubo cardiomyopathy

Tako-tsubo cardiomyopathy (TTC) is increasingly diagnosed in the United States, especially in the Caucasian population. To evaluate the clinical features and outcome of patients with TTC, we evaluated 34 patients (32 women and 2 men) 22 to 88 years of age (mean 66 +/- 14) who fulfilled the following criteria: (1) akinesia or dyskinesia of the apical and/or midventricular segments of the left ventricle with regional wall motion abnormalities that extended beyond the distribution of a single epicardial vessel and (2) absence of obstructive coronary artery disease. Twenty-five patients (74%) presented with chest pain, 20 patients (59%) presented with dyspnea, and 8 patients (24%) presented with cardiogenic shock. Twenty-two patients (65%) had ST-segment elevation and 14 patients (41%) had T-wave inversion on presentation. Twenty-five patients (74%) reported a preceding stressful event. Cardiac biomarkers were often mildly increased, with a mean troponin I (peak) of 13.9 +/- 24. Mean +/- SD left ventricular ejection fractions were 28 +/- 10% at time of presentation and 51 +/- 14 at time of follow-up (p <0.0001). Two patients (6%) died during the hospital stay. Average duration of hospital stay was 6.6 +/- 6.2 days. In conclusion, TTC is common in postmenopausal women with preceding physical or emotional stress. It predominantly involves the apical portion of the left ventricle and patients with this condition have a favorable outcome with appropriate medical management. The precise cause remains unclear.

[Acute lung oedema during a tako-tsubo syndrome associated with mitral stenosis]

The tako-tsubo syndrome is the subject of a lot of publications focusing on the different circumstances of discovery (emotion, anesthetic stress...). We report the original case of a patient of 56 years with a tight mitral stenosis, hospitalized for acute lung oedema, sinus rhythm, in which the original data and follow-up studies have identified a tako-tsubo syndrome with favorable evolution.

Takotsubo cardiomyopathy: state-of-the-art review

Takotsubo cardiomyopathy (TC) is characterized by transient, often severe, left ventricular dysfunction and electrocardiographic changes that might mimic acute myocardial infarction in the absence of significant obstructive coronary artery disease. It is often encountered in elderly women after physical or emotional stress. Excessive catecholamine stimulation, metabolic abnormalities, and microcirculatory dysfunction are thought to be responsible for the manifestations of this disorder. This comprehensive review summarizes relevant published data, atypical presentations, pathophysiology, and management strategy. It also includes a review of 789 patients with TC including nine illustrative cases encountered at our institution.

[Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome]

Takotsubo is a reversible cardiomyopathy, often triggered by a stressful event. It combines clinical features mimicking a myocardial infarction, transient apical ballooning of the left ventricle, normal coronary arteries and a small rise in troponin level. There is a striking female predominance with mean age ranging from 65 to 76 years among series. Preceding stressful event is documented in 50 to 100% of patients. The most common clinical presentation is an angor-like chest pain with ST-segment elevation on the electrocardiogram (70%). The prognosis is excellent even if serious complications may occur: pulmonary oedema, cardiogenic shock, transient dynamic intraventricular gradient, life-threatening arrhythmias. In-hospital mortality is in the range of 0 to 10%. The recurrence rate is low. The precise physiopathology of the syndrome remains unknown but catecholamine mediated myocardial stunning is the most favored explanation.

[Contribution of cardiac MRI in the etiologic diagnosis of chest pain syndrome with a normal angiographic aspect of the coronary arteries]

The etiologic diagnosis of chest pain with elevation of specific cardiac enzymes, repolarization abnormalities and a normal angiographic aspect of the coronary arteries is difficult. In this situation, the role of cardiac MRI is growing, frequently allowing to precise the etiology of the chest pain. We present a literature review concerning the semiology of the cardiac MRI in the three main involved etiologies: myocarditis, takotsubo syndrome, and myocardial ischemia with a normal angiographic aspect of the coronary arteries.

Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review

BACKGROUND

Transient left ventricular apical ballooning syndrome (TLVABS) is an acute cardiac syndrome mimicking ST-segment elevation myocardial infarction characterized by transient wall-motion abnormalities involving apical and mid-portions of the left ventricle in the absence of significant obstructive coronary disease.

METHODS

Searching the MEDLINE database 28 case series met the eligibility criteria and were summarized in a narrative synthesis of the demographic characteristics, clinical features and pathophysiological mechanisms.

RESULTS

TLVABS is observed in 0.7-2.5% of patients with suspected ACS, affects women in 90.7% (95% CI: 88.2-93.2%) with a mean age ranging from 62 to 76 years and most commonly presents with chest pain (83.4%, 95% CI: 80.0-86.7%) and dyspnea (20.4%, 95% CI: 16.3-24.5%) following an emotionally or physically stressful event. ECG on admission shows ST-segment elevations in 71.1% (95% CI: 67.2-75.1%) and is accompanied by usually mild elevations of Troponins in 85.0% (95% CI: 80.8-89.1%). Despite dramatic clinical presentation and substantial risk of heart failure, cardiogenic shock and arrhythmias, LVEF improved from 20-49.9% to 59-76% within a mean time of 7-37 days with an in-hospital mortality rate of 1.7% (95% CI: 0.5-2.8%), complete recovery in 95.9% (95% CI: 93.8-98.1%) and rare recurrence. The underlying etiology is thought to be based on an exaggerated sympathetic stimulation.

CONCLUSION

TLVABS is a considerable differential diagnosis in ACS, especially in postmenopausal women with a preceding stressful event. Data on longterm follow-up is pending and further studies will be necessary to clarify the etiology and reach consensus in acute and longterm management of TLVABS.