1
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Yamamoto H, Akiba H, Inagawa H, Okada Y. Isolated right ventricular takotsubo cardiomyopathy presenting as acute right ventricular failure: A case report. Heliyon 2023; 9:e17607. [PMID: 37416672 PMCID: PMC10320258 DOI: 10.1016/j.heliyon.2023.e17607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2023] [Revised: 06/21/2023] [Accepted: 06/22/2023] [Indexed: 07/08/2023] Open
Abstract
Background Takotsubo cardiomyopathy (TTC) is a non-ischaemic cardiomyopathy, characterized by transient wall motion abnormalities of the left ventricle. Although biventricular involvements are common with a poor prognosis, isolated right ventricular (RV) involvement of TTC is a rare, and its diagnosis remains challenging. Case presentation We encountered a case of isolated RV-TTC presenting as acute RV failure, with progression to cardiogenic shock requiring intensive treatment. Conflicting echocardiographic findings of RV asynergy with RV enlargement despite normal left ventricular wall motion and mild tricuspid regurgitation led to the correct diagnosis. Finally, the patient showed complete recovery with normalization of cardiac structure and function. Conclusions This case underscores the clinical significance of considering isolated RV-TTC as a new distinct variant form of TTC in terms of presentation, diagnostic findings, differential diagnosis, treatment strategy, and prognosis.
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Affiliation(s)
- Hiroyuki Yamamoto
- Department of Cardiovascular Medicine, Showa General Hospital, Tokyo, Japan
- Department of Cardiovascular Medicine, Narita-Tomisato Tokushukai Hospital, Chiba, Japan
| | - Haruna Akiba
- Department of Critical Care and Emergency Medicine, Showa General Hospital, Tokyo, Japan
| | - Hiroshi Inagawa
- Department of Critical Care and Emergency Medicine, Showa General Hospital, Tokyo, Japan
| | - Yasusei Okada
- Department of Critical Care and Emergency Medicine, Showa General Hospital, Tokyo, Japan
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2
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Flanagan K, Dezman ZDW, Dachroeden KJ, Bontempo LJ. 73-year-old Female with Syncope and Motor Vehicle Collision. Clin Pract Cases Emerg Med 2021; 5:369-376. [PMID: 34813422 PMCID: PMC8610462 DOI: 10.5811/cpcem.2021.7.53384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Accepted: 07/27/2021] [Indexed: 11/20/2022] Open
Abstract
Introduction Patients with traumatic injuries can be difficult to assess, and their evaluation often evolves in the emergency department (ED). We describe how an ED attending physician member developed a differential diagnosis for this presentation, arrived at a suspected diagnosis, and what test he proposed to prove his hypothesis. Case Presentation This clinicopathological case presentation details the initial assessment and management of a 73-year-old female who presented to the ED following a motor vehicle collision precipitated by a syncopal episode. Conclusion The final surprising diagnosis is then revealed.
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Affiliation(s)
- Kevin Flanagan
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Zachary D W Dezman
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland.,University of Maryland, Department of Epidemiology and Public Health, Baltimore, Maryland
| | - Karl J Dachroeden
- University of Maryland Medical Center, Department of Emergency Medicine, Baltimore, Maryland
| | - Laura J Bontempo
- University of Maryland School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
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3
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Omerovic E, Citro R, Bossone E, Redfors B, Backs J, Bruns B, Ciccarelli M, Couch LS, Dawson D, Grassi G, Iacoviello M, Parodi G, Schneider B, Templin C, Ghadri JR, Thum T, Chioncel O, Tocchetti CG, Van Der Velden J, Heymans S, Lyon AR. Pathophysiology of Takotsubo syndrome - a joint scientific statement from the Heart Failure Association Takotsubo Syndrome Study Group and Myocardial Function Working Group of the European Society of Cardiology - Part 2: vascular pathophysiology, gender and sex hormones, genetics, chronic cardiovascular problems and clinical implications. Eur J Heart Fail 2021; 24:274-286. [PMID: 34655287 DOI: 10.1002/ejhf.2368] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2020] [Revised: 10/10/2021] [Accepted: 10/10/2021] [Indexed: 01/09/2023] Open
Abstract
While the first part of the scientific statement on the pathophysiology of Takotsubo syndrome was focused on catecholamines and the sympathetic nervous system, in the second part we focus on the vascular pathophysiology including coronary and systemic vascular responses, the role of the central and peripheral nervous systems during the acute phase and abnormalities in the subacute phase, the gender differences and integrated effects of sex hormones, genetics of Takotsubo syndrome including insights from microRNA studies and inducible pluripotent stem cell models of Takotsubo syndrome. We then discuss the chronic abnormalities of cardiovascular physiology in survivors, the limitations of current clinical and preclinical studies, the implications of the knowledge of pathophysiology for clinical management and future perspectives and directions of research.
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Affiliation(s)
- Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Rodolfo Citro
- Heart Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Eduardo Bossone
- Division of Cardiology, A. Cardarelli Hospital, Naples, Italy
| | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital and Department of Molecular and Clinical Medicine/Wallenberg Laboratory, Institute of Medicine, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Johannes Backs
- Institute of Experimental Cardiology, Heidelberg University, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Heidelberg, Germany
| | - Bastian Bruns
- Institute of Experimental Cardiology, Heidelberg University, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research) Partner Site Heidelberg/Mannheim, Heidelberg, Germany.,Department of General Internal Medicine and Psychosomatics, University of Heidelberg, Heidelberg, Germany
| | - Michele Ciccarelli
- Department of Medicine, Surgery, and Dentistry, University of Salerno, Salerno, Italy
| | - Liam S Couch
- National Heart and Lung Institute, Imperial College, London, UK
| | - Dana Dawson
- Aberdeen Cardiovascular and Diabetes Centre, School of Medicine and Dentistry, University of Aberdeen, Aberdeen, Scotland, UK
| | - Guido Grassi
- Clinica Medica, University of Milano Bicocca, Milan, Italy
| | - Massimo Iacoviello
- University Cardiology Unit, Cardiothoracic Department, University Hospital, Bari, Italy
| | - Guido Parodi
- Clinical and Interventional Cardiology, Sassari University Hospital, Sassari, Italy
| | | | - Christian Templin
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Jelena R Ghadri
- University Heart Center, Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies, Hannover Medical School, Hannover, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania and University of Medicine Carol Davila, Bucharest, Romania
| | - C Gabriele Tocchetti
- Department of Translational Medical Sciences and Interdepartmental Center for Clinical and Translational Research (CIRCET), Federico II University, Naples, Italy
| | - Jolanda Van Der Velden
- Department of Physiology, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stephane Heymans
- Department of Cardiology, CARIM School for Cardiovascular Diseases, Maastricht University Medical Centre, Maastricht, The Netherlands.,Department of Cardiovascular Sciences, Centre for Molecular and Vascular Biology and Department of Cardiovascular Sciences, University of Leuven, Leuven, Belgium
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College, London, UK.,Department of Cardiology, Royal Brompton Hospital, London, UK
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4
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Redfors B, Jha S, Thorleifsson S, Jernberg T, Angerås O, Frobert O, Petursson P, Tornvall P, Sarno G, Ekenbäck C, Ravn-Fisher A, Y-Hassan S, Lyon AR, James S, Erlinge D, Omerovic E. Short- and Long-Term Clinical Outcomes for Patients With Takotsubo Syndrome and Patients With Myocardial Infarction: A Report From the Swedish Coronary Angiography and Angioplasty Registry. J Am Heart Assoc 2021; 10:e017290. [PMID: 34465127 PMCID: PMC8649294 DOI: 10.1161/jaha.119.017290] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background Takotsubo syndrome (TS) is a potentially life‐threatening acute cardiac syndrome with a clinical presentation similar to myocardial infarction and for which the natural history, management, and outcome remain incompletely understood. Our aim was to assess the relative short‐term mortality risk of TS, ST‐segment–elevation myocardial infarction (STEMI), and non‐STEMI (NSTEMI) and to identify predictors of in‐hospital complications and poor prognosis in patients with TS. Methods and Results This is an observational cohort study based on the data from the SCAAR (Swedish Coronary Angiography and Angioplasty Registry). We included all patients (n=117 720) who underwent coronary angiography in Sweden attributed to TS (N=2898 [2.5%]), STEMI (N=48 493 [41.2%]), or NSTEMI (N=66 329 [56.3%]) between January 2009 and February 2018. We compared patients with TS to those with NSTEMI or STEMI. The primary end point was all‐cause mortality at 30 days. Secondary outcomes were acute heart failure (Killip Class ≥2) and cardiogenic shock (Killip Class 4) at the time of angiography. Patients with TS were more often women compared with patients with STEMI or NSTEMI. TS was associated with unadjusted and adjusted 30‐day mortality risks lower than STEMI (adjusted hazard ratio [adjHR], 0.60; 95% CI, 0.48–0.76; P<0.001), but higher than NSTEMI (adjHR, 2.70; 95% CI, 2.14–3.41; P<0.001). Compared with STEMI, TS was associated with a similar risk of acute heart failure (adjHR, 1.26; 95% CI, 0.91–1.76; P=0.16) but a lower risk of cardiogenic shock (adjHR, 0.55; 95% CI, 0.34–0.89; P=0.02). The relative 30‐day mortality risk for TS versus STEMI and NSTEMI was higher for smokers than nonsmokers (adjusted P interaction STEMI=0.01 and P interaction NSTEMI=0.01). Conclusions The 30‐day mortality rate in TS was higher than in NSTEMI but lower than STEMI despite a similar risk of acute heart failure in TS and STEMI. Among patients with TS, smoking was an independent predictor of mortality.
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Affiliation(s)
- Björn Redfors
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Sandeep Jha
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | | | - Tomas Jernberg
- Department of Clinical Sciences Danderyd University HospitalKarolinska Institutet Stockholm Sweden
| | - Oskar Angerås
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Ole Frobert
- The Department of Cardiology Faculty of Health Örebro University Örebro Sweden
| | - Petur Petursson
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Per Tornvall
- Department of Clinical Science and Education Södersjukhuset Karolinska Institute Stockholm Sweden
| | - Giovanna Sarno
- The Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
| | - Christina Ekenbäck
- Department of Clinical Sciences, Danderyd Hospital, Division of Cardiovascular Medicine Karolinska Institutet Stockholm Sweden
| | - Annika Ravn-Fisher
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
| | - Shams Y-Hassan
- The Department of Medicine Karolinska University Hospital Huddinge Stockholm Sweden
| | - Alexander R Lyon
- NIHR Cardiovascular Biomedical Research Unit Royal Brompton Hospital London United Kingdom.,National Heart and Lung InstituteImperial College London United Kingdom
| | - Stefan James
- The Department of Medical Sciences, Cardiology Uppsala University Uppsala Sweden
| | - David Erlinge
- The Department of Cardiology Skåne University Hospital Lund Sweden
| | - Elmir Omerovic
- Department of Cardiology Sahlgrenska University Hospital Gothenburg Sweden
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5
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Ong GJ, Girolamo O, Stansborough J, Nguyen TH, Horowitz JD. Incidence and clinical/laboratory correlates of early hypotension in takotsubo syndrome. ESC Heart Fail 2021; 8:2009-2015. [PMID: 33760362 PMCID: PMC8120397 DOI: 10.1002/ehf2.13277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 01/26/2021] [Accepted: 02/11/2021] [Indexed: 12/11/2022] Open
Abstract
Aims Takotsubo syndrome (TTS) is a form of acute myocardial inflammation, often triggered by catecholamine release surges, which accounts for approximately 10% of ‘myocardial infarctions’ in female patients above the age of 50. Its associated substantial risk of in‐hospital mortality is mainly driven by the development of hypotension and shock. While hypotension is induced largely by factors other than low cardiac output, its precise cause is unknown, and clinical parameters associated with hypotension have not been identified previously. We therefore sought to identify the incidence and clinical/laboratory correlates of early hypotension in TTS. Methods and results We analysed the in‐hospital data of patients recruited to the South Australian TTS Registry. Associations between the development of hypotension, patient demographics, severity of the acute TTS attack, and key biochemical markers were sought. One hundred thirteen out of 319 patients (35%) were hypotensive (median systolic blood pressure 80 mmHg) during their index hospitalization. Development of hypotension preceded all in‐hospital deaths (n = 8). On univariate analyses, patients who developed hypotension had lower left ventricular ejection fraction (P = 0.009), and higher plasma N‐terminal pro brain natriuretic peptide and troponin‐T concentrations (P = 0.046 and 0.008, respectively), all markers of severity of the TTS attack; hypotension also occurred less commonly in male than in female patients (P = 0.014). On multivariate linear regression analysis, female sex and lower left ventricular ejection fraction were independent correlates of the development of hypotension (P = 0.009 and 0.010, respectively). Conclusions Early development of hypotension is very common in TTS, and its presence is associated with a substantial risk of in‐hospital mortality. Hypotension is a marker of severe TTS attacks and occurs more commonly in female TTS patients.
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Affiliation(s)
- Gao Jing Ong
- Cardiology Unit, Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Basil Hetzel Institute, University of Adelaide, Woodville, South Australia, 5011, Australia
| | - Olivia Girolamo
- Basil Hetzel Institute, University of Adelaide, Woodville, South Australia, 5011, Australia
| | | | - Thanh Ha Nguyen
- Cardiology Unit, Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Basil Hetzel Institute, University of Adelaide, Woodville, South Australia, 5011, Australia
| | - John David Horowitz
- Cardiology Unit, Queen Elizabeth Hospital, Woodville, South Australia, Australia.,Basil Hetzel Institute, University of Adelaide, Woodville, South Australia, 5011, Australia
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6
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Agdamag AC, Patel H, Chandra S, Rao A, Suboc TM, Marinescu K, Ledsky C, Volgman AS. Sex Differences in Takotsubo Syndrome: A Narrative Review. J Womens Health (Larchmt) 2020; 29:1122-1130. [DOI: 10.1089/jwh.2019.7741] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Arianne Clare Agdamag
- Department of Internal Medicine, Rush University Medical Center, Chicago, Illinois, USA
| | - Hena Patel
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Sonal Chandra
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Anupama Rao
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Tisha Marie Suboc
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Karolina Marinescu
- Division of Cardiology, Rush University Medical Center, Chicago, Illinois, USA
| | - Clara Ledsky
- Rush Medical College, Rush University Medical Center, Chicago, Illinois, USA
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7
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An Update on Cardiac Magnetic Resonance Imaging in Takotsubo Cardiomyopathy. CURRENT CARDIOVASCULAR IMAGING REPORTS 2020. [DOI: 10.1007/s12410-020-09536-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Abstract
Purpose of Review
To provide an update on the use of cardiac magnetic resonance imaging in the diagnosis of Takotsubo cardiomyopathy.
Recent Findings
Long-term prognosis of Takotsubo cardiomyopathy may not be as clear-cut as previously thought. Cardiac magnetic resonance imaging not only allows differentiation between reversible and nonreversible changes but has an emerging role in identifying cellular level changes associated with prognostic indicators such as myocardial energetics using 31P-CMR spectroscopy and detection of myocardial inflammation overlying myocardial oedema, using ultrasmall paramagnetic iron oxide particle uptake in macrophages.
Summary
Takotsubo cardiomyopathy is a non-ischemic acute heart failure syndrome. It is commonly triggered by emotional or physical stress and is possibly the strongest psychosomatic interaction seen in medicine. While clinically its presentation mimics a myocardial infarction, the acute imaging characteristics are critical in correctly identifying the disease entity.
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8
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Ong GJ, Nguyen TH, Stansborough J, Surikow SY, Horowitz JD. Incremental “Therapeutic” Myocardial Exposure to Catecholamines: Incidence and Impact in Takotsubo Syndrome. Cardiovasc Drugs Ther 2020; 34:95-100. [DOI: 10.1007/s10557-019-06918-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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9
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Abstract
Conditions associated with states of catecholamine toxicity are pheochromocytoma, paraganglioma, Takotsubo’s cardiomyopathy, and catecholaminergic polymorphic ventricular tachycardia. This article defines these conditions along with relevant diagnostic and prognostic factors. The role of catecholamines in these conditions are compared and contrasted. Emphasis is given to the role of endothelial dysfunction as a possible etiologic factor in cardiomyopathy associated with excess catecholamines.
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Affiliation(s)
- Pooja Sethi
- Cardiology, Texas Tech University Health Sciences Center, Lubbock, USA
| | - Craig D Peiris
- Cardiology, Texas Tech University Health Sciences Center, Lubbock, USA
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10
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Ludhwani D, Rahaby M, Patel V, Jamil S, Kedzia A, Wu C. Implications of Left Bundle Branch Block in Takotsubo Cardiomyopathy: Propensity Match Analysis from the National Inpatient Sample. Cardiol Ther 2019; 8:253-265. [PMID: 31317468 PMCID: PMC6828991 DOI: 10.1007/s40119-019-0141-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Indexed: 01/02/2023] Open
Abstract
INTRODUCTION Takotsubo cardiomyopathy (TTC), also called stress cardiomyopathy, is a transient reversible left ventricular dysfunction mimicking acute coronary syndrome (ACS). Studies have shown similar rates of in-hospital complications in TTC and myocardial infarction (MI). Left bundle branch block (LBBB) is associated with increased mortality in patients with MI; however, similar studies comparing outcomes of TTC in the presence of LBBB are lacking. METHODS The 2016 National Inpatient Sample (NIS) database was queried to identify all admissions with a primary discharge diagnosis of TTC. Diagnosis-specific codes were used to stratify patients based on the presence or absence of LBBB. Both population sets were paired using 1:10 propensity score matching. Multivariate logistic regression analysis was performed to compare various in-hospital outcomes among both groups. RESULTS Amongst 7270 admissions for TTC, 226 patients had concomitant LBBB. After performing 1:10 propensity matching, 130 patients with LBBB were compared to 1275 patients without LBBB. The presence of LBBB was associated with increased odds of cardiogenic shock (AOR = 2.2, 95% CI 1.21-3.99, p = 0.0097); ventricular arrhythmia (AOR 1.99, 95% CI 1.11-3.57, p = 0.02), acute congestive heart failure (AOR = 1.49, 95% CI 1.01-2.2, p = 0.04), and sudden cardiac arrest (AOR = 3.37, 95% CI 1.59-7.13, p = 0.0001). There was no statistical difference in all-cause in-hospital mortality, however a trend towards worsening was noted. CONCLUSIONS The incidence of arrhythmia and shock in patients with TTC does not correlate with the extent of myocardium involvement. The presence of LBBB in such cases can help recognize at-risk populations, and with timely intervention, life-threatening complications can be avoided. Despite limitations of the dataset and inability to establish causality, prospective studies with longer follow-up are warranted.
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Affiliation(s)
- Dipesh Ludhwani
- Chicago Medical School, Rosalind Franklin University, Northwestern McHenry Hospital, 4309 West Medical Center Drive, McHenry, IL, 60050, USA.
| | - Mouyyad Rahaby
- Chicago Medical School, Rosalind Franklin University, Northwestern McHenry Hospital, 4309 West Medical Center Drive, McHenry, IL, 60050, USA
| | - Vasu Patel
- Chicago Medical School, Rosalind Franklin University, Northwestern McHenry Hospital, 4309 West Medical Center Drive, McHenry, IL, 60050, USA
| | - Saad Jamil
- Chicago Medical School, Rosalind Franklin University, Northwestern McHenry Hospital, 4309 West Medical Center Drive, McHenry, IL, 60050, USA
| | - Adam Kedzia
- Chicago Medical School, Rosalind Franklin University, Northwestern McHenry Hospital, 4309 West Medical Center Drive, McHenry, IL, 60050, USA
| | - Chunyi Wu
- University of Michigan, 500 S State St, Ann Arbor, MI, 48109, USA
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11
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Redfors B. Admission heart rate in the Takotsubo syndrome - An early marker of the severity of cardiac dysfunction and the risk of in-hospital complications. Int J Cardiol 2018; 273:52-53. [PMID: 30224260 DOI: 10.1016/j.ijcard.2018.09.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Accepted: 09/03/2018] [Indexed: 12/22/2022]
Affiliation(s)
- Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Clinical Trials Center, Cardiovascular Research Foundation, NY, New York, United States of America..
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12
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Jha S, Zeijlon R, Shekka Espinosa A, Alkhoury J, Oras J, Omerovic E, Redfors B. Clinical management in the takotsubo syndrome. Expert Rev Cardiovasc Ther 2018; 17:83-93. [DOI: 10.1080/14779072.2019.1556098] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Affiliation(s)
- Sandeep Jha
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Internal Medicine, Kungälv Hospital, Kungälv, Sweden
| | - Rickard Zeijlon
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Aaron Shekka Espinosa
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jessica Alkhoury
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Jonatan Oras
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Laboratory, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
- Clinical Trial Center, Cardiovascular Research Foundation, New York, NY, USA
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13
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Anabtawi A, Roldan PC, Roldan CA. Takotsubo Cardiomyopathy With a Rapidly Resolved Left Ventricular Thrombus. J Investig Med High Impact Case Rep 2017; 5:2324709617734238. [PMID: 28989934 PMCID: PMC5624350 DOI: 10.1177/2324709617734238] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2017] [Revised: 07/21/2017] [Accepted: 07/29/2017] [Indexed: 01/27/2023] Open
Abstract
This article presents the case of a 53-year-old man who presented with acute right superficial femoral and popliteal arterial thrombosis for which he underwent an emergent uncomplicated thrombectomy. He denied preceding cardiovascular or neurologic symptomatology and had no history of coronary or peripheral arterial disease, trauma, hypercoagulability, or malignancy. However, he reported having several days of intense emotional stress prior to presentation. His cardiac exam was normal, his electrocardiogram showed normal sinus rhythm and nonspecific ST-T wave abnormalities, and his troponin levels were normal. Transthoracic echocardiography (TTE) revealed a large (2.4 × 2 cm) apical left ventricle (LV) thrombus, LV apical akinesis, and LV ejection fraction of 40% to 45%. Coronary angiography revealed only luminal irregularities. A repeat TTE performed 3 days after initiating unfractionated heparin revealed complete resolution of the LV thrombus. The patient had an uneventful clinical course and was discharged home in stable condition on oral anticoagulants. The lower incidence of LV thrombus in takotsubo cardiomyopathy (TC) of 1.3% in comparison to 4% to 8% in acute myocardial infarction due to coronary artery disease in the current era of early reperfusion may be explained by the lower extent of ischemic myocardial necrosis associated with TC. This case suggests that the lower extent of myocardial necrosis in TC may also lead to faster resolution of LV thrombus. Therefore, earlier follow-up with TTE (within 2 weeks) and shorter duration of anticoagulation (<3 months) may be considered in patients with TC complicated by LV thrombus formation with or without systemic embolism.
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Affiliation(s)
| | | | - Carlos A Roldan
- University of New Mexico, Albuquerque, NM, USA.,New Mexico VA Health Care Center, Albuquerque, NM, USA
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14
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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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15
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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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16
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Becher T, El-Battrawy I, Baumann S, Fastner C, Behnes M, Loßnitzer D, Elmas E, Hoffmann U, Papavassiliu T, Kuschyk J, Dösch C, Röger S, Hillenbrand D, Schramm K, Borggrefe M, Akin I. Characteristics and long-term outcome of right ventricular involvement in Takotsubo cardiomyopathy. Int J Cardiol 2016; 220:371-5. [PMID: 27390957 DOI: 10.1016/j.ijcard.2016.06.240] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 06/26/2016] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy (SCM) resembles a reversible cardiomyopathy that is characterized by localized wall motion abnormalities in the absence of stenotic coronary vascular disease. Patients typically present with apical ballooning of the left ventricle (LV), however the right ventricle (RV) is also affected in up to 50.0% of patients. Long-term prognosis of classical SCM resembles that of patients after ST elevation myocardial infarction. Data on long-term prognosis of biventricular compared to classical SCM is controversial. The aim of this study was therefore to analyze patients with biventricular SCM regarding in-hospital outcome and long-term prognosis. MATERIALS AND METHODS 114 consecutive patients with SCM were retrospectively analyzed. 88 patients presented with classical SCM, 26 patients (22.8%) were diagnosed with biventricular SCM. Follow-up was conducted for a total of 4.4years. Mean age was 67.1years with 83.3% of patients being female. The primary endpoint was a composite of all-cause mortality, recurrence of SCM and re-hospitalization due to heart failure. RESULTS Although patients with biventricular SCM presented with a tendency towards an increased rate of cardiogenic shock (30.8% vs. 15.9%; p=0.09) and significantly more usage of inotropic support upon hospital admission (34.6% vs. 13.6%; p=0.01), there was no difference concerning the primary endpoint in both groups (50.0% vs. 44.3%; p=0.31). Furthermore, there was no difference in mortality both in-hospital (7.7% vs. 7.9%; p=0.66) and during long-term follow-up (27.3% vs. 23.1%; p=0.46). CONCLUSION Patients with biventricular SCM have the same in-hospital and long-term outcome compared to classical SCM.
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Affiliation(s)
- Tobias Becher
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany.
| | - Ibrahim El-Battrawy
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Stefan Baumann
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Christian Fastner
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Dirk Loßnitzer
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Elif Elmas
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Ursula Hoffmann
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Theano Papavassiliu
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Jürgen Kuschyk
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Christina Dösch
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Susanne Röger
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Dennis Hillenbrand
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Katja Schramm
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine Mannheim, University Medical Centre Mannheim (UMM), University of Heidelberg, Germany, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany; DZHK (German Centre for Cardiovascular Research), Partner Site, Heidelberg-Mannheim, Mannheim, Germany
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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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Scally C, Ahearn T, Rudd A, Neil CJ, Srivanasan J, Jagpal B, Horowitz J, Frenneaux M, Dawson DK. Right Ventricular Involvement and Recovery After Acute Stress-Induced (Tako-tsubo) Cardiomyopathy. Am J Cardiol 2016; 117:775-80. [PMID: 26782339 DOI: 10.1016/j.amjcard.2015.11.057] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 01/23/2023]
Abstract
Acute stress-induced (Tako-tsubo) cardiomyopathy is an increasingly recognized but insufficiently characterized syndrome. Here, we investigate the pathophysiology of right ventricular (RV) involvement in Tako-tsubo and its recovery time course. We prospectively recruited 31 patients with Tako-tsubo with predominantly ST-elevation electrocardiogram and 18 controls of similar gender, age, and co-morbidity distribution. Patients underwent echocardiography and cardiac magnetic resonance (CMR) imaging on a 3T Philips scanner in the acute phase (day 0 to 3 after presentation) and at 4-months follow-up. Visually, echocardiography was able to identify only 52% of patients who showed RV wall motion abnormalities on CMR. Only CMR-derived RV ejection fraction (p = 0.01) and echocardiography-estimated pulmonary artery pressure (p = 0.01) identify RV functional involvement in the acute phase. Although RV ejection fraction normalizes in most patients by 4 months, acutely there is RV myocardial edema in both functioning and malfunctioning segments, as measured by prolonged native T1 mapping (p = 0.02 for both vs controls), and this persists at 4 months in the acutely malfunctioning segments (p = 0.002 vs controls). The extracellular volume fraction was significantly increased acutely in all RV segments and remained increased at follow-up compared with controls (p = 0.004 for all). In conclusion, in a Tako-tsubo population presenting predominantly with ST-elevation electrocardiogram, we demonstrate that although RV functional involvement is seen in only half of the patients, RV myocardial edema is present acutely throughout the RV myocardium in all patients and results in microscopic fibrosis at 4-month follow-up.
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Affiliation(s)
- Caroline Scally
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - Trevor Ahearn
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - Amelia Rudd
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Janaki Srivanasan
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - Baljit Jagpal
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | | | - Michael Frenneaux
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom
| | - Dana K Dawson
- School of Medicine and Dentistry, University of Aberdeen, Aberdeen, United Kingdom.
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Reply: To PMID 25772741. Am J Cardiol 2015; 115:1785-6. [PMID: 25937353 DOI: 10.1016/j.amjcard.2015.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/02/2015] [Indexed: 11/21/2022]
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20
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Singh K, Carson K, Hibbert B, Le May M. Natural history of cardiac arrest in patients with takotsubo cardiomyopathy. Am J Cardiol 2015; 115:1466-72. [PMID: 25772741 DOI: 10.1016/j.amjcard.2015.02.023] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 02/13/2015] [Accepted: 02/13/2015] [Indexed: 02/07/2023]
Abstract
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.
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Singh K, Chong CR, Nguyen TH, Stansborough J, Horowitz JD. Reply: Takotsubo Syndrome is a Systemic, rather than Merely a Cardiac, Disease: Possible Effects on the Systemic and Pulmonary Vasculature. Heart Lung Circ 2015; 24:417-8. [DOI: 10.1016/j.hlc.2014.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 10/24/2014] [Indexed: 10/24/2022]
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