Transient mid-ventricular ballooning cardiomyopathy: A new entity of Takotsubo cardiomyopathy

Role of miR-204 in segmental cardiac effects of phenylephrine and pressure overload

Cardiotoxicity caused by adrenergic receptor agonists overdosing or stress-induced catecholamine release promotes cardiomyopathy, resembling Takotsubo cardiomyopathy (TC). TC is characterized by transient regional systolic dysfunction of the left ventricle. The animal models of TC and modalities for assessing regional wall motion abnormalities in animal models are lacking. We previously reported the protective role of a small noncoding microRNA-204-5p (miR-204) in cardiomyopathies, but its role in TC remains unknown. Here we compared the impact of miR-204 absence on phenylephrine (PE)-induced and transaortic constriction (TAC)-induced changes in cardiac muscle motion in the posterior and anterior apical, mid, and basal segments of the left ventricle using 2-dimensional speckle-tracking echocardiography (2-STE). Wildtype and miR-204-/- mice were subjected to cardiac stress in the form of PE for four weeks or TAC-induced pressure overload for five weeks. PE treatment increased longitudinal and radial motion in the apex of the left ventricle and shortened the peak motion time of all left ventricle segments. The TAC led to decreased longitudinal and radial motion in the left ventricle segments, and there was no difference in the peak motion time. Compared to wildtype mice, PE-induced peak cardiac muscle motion time in the anterior base of the left ventricle was significantly earlier in the miR-204-/- mice. There was no difference in TAC-induced peak cardiac muscle motion time between wildtype and miR-204-/- mice. Our findings demonstrate that PE and TAC induce regional wall motion abnormalities that 2-STE can detect. It also highlights the role of miR-204 in regulating cardiac muscle motion during catecholamine-induced cardiotoxicity.

Takotsubo syndrome is a coronary microvascular disease: experimental evidence

BACKGROUND AND AIMS

Takotsubo syndrome (TTS) is a conundrum without consensus about the cause. In a murine model of coronary microvascular dysfunction (CMD), abnormalities in myocardial perfusion played a key role in the development of TTS.

METHODS AND RESULTS

Vascular Kv1.5 channels connect coronary blood flow to myocardial metabolism and their deletion mimics the phenotype of CMD. To determine if TTS is related to CMD, wild-type (WT), Kv1.5-/-, and TgKv1.5-/- (Kv1.5-/- with smooth muscle-specific expression Kv1.5 channels) mice were studied following transaortic constriction (TAC). Measurements of left ventricular (LV) fractional shortening (FS) in base and apex, and myocardial blood flow (MBF) were completed with standard and contrast echocardiography. Ribonucleic Acid deep sequencing was performed on LV apex and base from WT and Kv1.5-/- (control and TAC). Changes in gene expression were confirmed by real-time-polymerase chain reaction. MBF was increased with chromonar or by smooth muscle expression of Kv1.5 channels in the TgKv1.5-/-. TAC-induced systolic apical ballooning in Kv1.5-/-, shown as negative FS (P < 0.05 vs. base), which was not observed in WT, Kv1.5-/- with chromonar, or TgKv1.5-/-. Following TAC in Kv1.5-/-, MBF was lower in LV apex than in base. Increasing MBF with either chromonar or in TgKv1.5-/- normalized perfusion and function between LV apex and base (P = NS). Some genetic changes during TTS were reversed by chromonar, suggesting these were independent of TAC and more related to TTS.

CONCLUSION

Abnormalities in flow regulation between the LV apex and base cause TTS. When perfusion is normalized between the two regions, normal ventricular function is restored.

Kidney Failure among Patients with Takotsubo Syndrome or Myocardial Infarction: A Retrospective Analysis

Background: Takotsubo syndrome (TTS) is a syndrome with ambiguous pathophysiology. Impaired kidney function (KF) seems to impact the outcome of patients with TTS. We hypothesized that KF worsens the outcome among TTS patients and furthermore, TTS patients with concomitant KF experience more adverse events compared to myocardial infarction (MI) patients with concomitant KF. Methods and Results: This retrospective single-center study comprised two groups (cohorts) of patients including patients with TTS and concomitant KF (n = 61, 27.1%) and patients with MI and concomitant KF (n = 164, 72.9%). The clinical outcomes were delineated as short-term outcomes defined as in-hospital adverse events during index hospitalization and long-term outcomes defined as adverse events over five-year clinical follow-ups. All-cause mortality, stroke, cardiopulmonary resuscitation (CPR), life-threatening arrhythmias, need for respiratory support, and cardiogenic shock with subsequent use of inotropic agents during index hospitalization were denoted as in-hospital adverse events. All-cause mortality, rehospitalization due to heart failure, stroke, thromboembolic events, and the recurrence of primary pathology (TTS and MI) were analyzed during five-year follow-ups after index hospitalization. A higher mortality rate was noted among TTS patients with KF compared to TTS without KF. In addition, in-hospital event rates in patients with TTS and concomitant KF compared to MI and concomitant KF were comparable with the exception of a higher rate of respiratory support in TTS patients. The mortality rate was significantly higher among patients with TTS and KF at 4 years (29.5% vs. 15.9%, p = 0.02) and 5 years (34.4% vs. 20.7%, p = 0.03) in comparison to patients with MI and concomitant KF. In contrast, the rate of re-hospitalization related to heart failure was higher at 30 days, and at one-, four-, and five-year follow-ups in patients suffering from MI and KF compared to TTS and concomitant KF. Additionally, the recurrence of MI after 4 and 5 years was higher than the recurrence of TTS (4.9% vs. 15.2%; 4.9% vs. 16.5%). There were no differences in life-threatening arrhythmias and stroke in both groups. Conclusions: Patients with TTS and concomitant KF have higher all-cause mortality when compared to MI and concomitant KF. The mechanisms responsible remain to be determined.

Takotsubo syndrome: between evidence, myths, and misunderstandings

Takotsubo syndrome (TS) is an acute cardiac condition characterized by transient wall motion abnormalities mostly of the left ventricle. First described in 1990, TS has gained substantial attention during the past 15 years. However, the disease is still underdiagnosed. Prospective studies on TS are largely lacking, and the condition remains incompletely understood. In addition, significant misconceptions and misunderstandings are evident, contributing to potentially severe underestimation. Here, we review important aspects of TS with a focus on pitfalls, misinterpretations, and knowledge gaps considered important during diagnosis and management of the disease.

Coincidental coronary artery disease impairs outcome in patients with takotsubo cardiomyopathy

BACKGROUND AND AIM

Takotsubo cardiomyopathy (TC) is an important differential diagnosis of coronary artery disease (CAD), mimicking acute coronary syndrome in clinical symptoms, biomarker profiles and ST-elevation in ECG. Absence of occlusive coronary disease is an essential criterion distinguishing both diseases. The aim of the study was to explore the influence of co-existing incidental CAD on poorer clinical outcomes and all-cause mortality in TC.

DESIGN, METHODS AND RESULTS

Our mono-centric study cohort constituted 114 consecutive patients diagnosed with TC between 2003 and 2015. The primary endpoint was the all-cause mortality. Additionally, we compared the incidence of thromboembolic events, life-threatening arrhythmias, cardiogenic shock and in-hospital death. There was no significant difference in gender distribution or mean age in both groups. Patients diagnosed with a co-existing CAD (n = 22), had a more pronounced cardiovascular risk profile. The all-cause mortality among patients with co-existing CAD after a 2-year follow-up was higher than those diagnosed with lone TC (22.7 vs. 5.4 %, P = 0.07). In a multivariate cox regression analysis CAD (HR 3.5, 95 %CI 1.0-11.6; P = 0.04), LVEF ≤ 35% (HR 3.8, 95% CI 0.0-0.6, P = 0.01) and cardiogenic shock (HR 3.8, 95% CI 1.2-11.3; P = 0.01) were independent predictors of the primary endpoint.

CONCLUSION

Our study reveals that co-existing CAD impairs the outcome in patients with TC. The diagnostic work-up for TC should therefore not necessarily hinge on ruling out CAD.

Postpartum woman with pneumomediastinum and reverse (inverted) takotsubo cardiomyopathy: a case report

Introduction

Pneumomediastinum is known to occur during labor. Patients typically present with chest pain and symptoms may be suspicious, for example of pulmonary embolism or aortic dissection. The condition itself, however, is rather harmless and self-limiting.

Takotsubo cardiomyopathy is associated with psychologically or physiologically stressful events and its symptoms mimic myocardial infarction. Yet, symptoms often improve quickly as the initially impaired cardiac function is usually restored within days or weeks.

Although the initial presentation of the patient in this case report was dramatic, the clinical course was positive and the patient could be quickly dismissed in a good general condition. To the best of our knowledge, no presentation of a combined occurrence of postpartum pneumomediastinum and reverse (inverted) takotsubo cardiomyopathy exists.

Case presentation

We present the case of a 30-year-old Caucasian woman with sudden onset of thoracic back and chest pain approximately 24 hours after an otherwise unremarkable vaginal delivery. A contrast-enhanced chest computed tomography showed cervical and mediastinal emphysema without proof for pulmonary embolism or aortic dissection. She received a symptomatic analgesic treatment and was dismissed to the obstetrics department for monitoring.

Within hours, slightly increased levels of troponin I were observed without corresponding electrocardiography changes. Immediate cardiac catheterization and a cardiovascular magnetic resonance imaging (performed within 24 hours) revealed basal to midventricular hypokinesia, but were otherwise unremarkable. A low-dose treatment for congestive heart failure was initiated, under which symptoms subsided within days. She was dismissed after 12 days in a good general condition.

Conclusions

Although the clinical presentation of the combination of the diseases initially was dramatic, the prognosis is positive. In the context of the preceding delivery, knowledge about the postpartum pneumomediastinum lets the radiologist of the emergency department quickly make this diagnosis. The takotsubo cardiomyopathy, however, needs broader diagnostics to not miss intervention-requiring causes.

Diagnostic utility of 123I-BMIPP imaging in patients with Takotsubo cardiomyopathy

OBJECTIVE

Takotsubo cardiomyopathy is a cardiac syndrome with an acute onset defined by chest symptoms and ST segment elevation on electrocardiograms. Takotsubo cardiomyopathy is sometimes misdiagnosed as acute myocardial infarction (AMI). Therefore a non-invasive diagnostic method is needed to be established for setting up appropriate strategies. The purpose of this study was to detect myocardial metabolic abnormalities and to determine the diagnostic usefulness of (123)I-beta-methy-iodophenyl pentadecanoic acid ((123)I-BMIPP) imaging in patients with takotsubo cardiomyopathy.

METHODS AND RESULTS

We examined 16 patients with takotsubo cardiomyopathy and 12 with AMI in the left anterior descending artery. All patients were studied with resting (123)I-BMIPP imaging. Total defect score (TDS) of (123)I-BMIPP and perfusion were semi-quantitatively determined with single-photon emission computed tomography (SPECT) imaging using a 17-segment 5-point model. TDS of (123)I-BMIPP were 4.8 ± 2.7 in patients with Takotsubo cardiomyopathy and 22.4 ± 10.7 in AMI. The ratio of summed BMIPP defect score of non-apical to apical segments in Takotsubo cardiomyopathy was smaller than that of the patients with AMI (0.1 ± 0.1 vs. 1.1 ± 0.7, p < 0.0001), indicating that (123)I-BMIPP abnormalities were exclusively observed the in apical area. The ratio of summed perfusion defect scores of non-apical to apical segments in takotsubo cardiomyopathy did not differ significantly from that of AMI (0.52 ± 0.6 vs. 0.57 ± 0.3, p = NS). Summed BMIPP defect score in the apical area of takotsubo cardiomyopathy was larger than that of perfusion defect score (3.9 ± 2.7 vs. 1.8 ± 1.8, p = 0.04).

CONCLUSION

Impaired metabolic metabolism exclusively in the apical region was observed by (123)I-BMIPP SPECT images in takotsubo cardiomyopathy. These typical metabolic SPECT features of the disease can be utilized on differential diagnosis of takotsubo cardiomyopathy.

Takotsubo cardiomyopathy recurrence with left ventricular apical ballooning following isolated right ventricular involvement: A case report

We report a case of Takotsubo cardiomyopathy, which involved the right ventricle at first presentation and demonstrated involvement of the left ventricle during recurrence. The patient was admitted to Kyung Hee University Hospital due to a left hip fracture, which was considered a result of physical stress. Complete recovery was confirmed by echocardiography prior to recurrence. The cause of the second event was surgery for the left hip fracture. Recurrence of Takotsubo cardiomyopathy at various cardiac locations provides evidence against the existing hypotheses that variants of Takotsubo cardiomyopathy are associated with anatomically different distributions of cardiac adrenergic receptors, the degree of stimulation by sympathetic activity and different susceptibilities to such sympathetic stimulation.

Takotsubo cardiomyopathy: an Australian single centre experience with medium term follow up

BACKGROUND

Takotsubo cardiomyopathy (TC) is increasingly recognised in patients presenting with features of acute coronary syndrome. We present a single centre experience of TC with medium term follow up.

METHODS

Fifty-two consecutive patients presenting with a diagnosis of TC were included. The clinical presentation, complications, baseline and follow-up echocardiograms and cardiac magnetic resonance imaging were analysed.

RESULTS

Fifty-one patients were female. A stressful event preceded presentation in 37 (71%) patients. Chest pain was the most common symptom (83%). Two patients presented with an out-of-hospital cardiac arrest. ST segment elevation (40%) and global T wave inversion (44%) were the most frequent electrocardiogram changes. Left ventricular assessment demonstrated typical apical ballooning in 41 patients and 11 patients demonstrated the mid-wall variant. In-hospital complications occurred in 11 patients (21%) and included acute pulmonary oedema (n = 2), cardiogenic shock (n = 5); two of whom had a significant left ventricular outflow gradient, atrial fibrillation (n = 1), left ventricular thrombus (n = 2) and a cerebrovascular event (n = 2). Left ventricular function at presentation and follow up was compared in 40 patients. The mean ejection fraction in this group at presentation was 47% (20-70%) compared with that at follow up of 63% (44-76%). There were no significant complications or recurrences at follow up.

CONCLUSIONS

While TC is a reversible condition with low rates of complications and recurrence at follow up it is, as demonstrated in our cohort, associated with significant in-hospital morbidity in a proportion of patients.

Takotsubo cardiomyopathy--a clinical review

Stress cardiomyopathy is characterised by reversible left ventricular dysfunction. It simulates an acute coronary syndrome (ACS), presenting with precordial pain or dyspnoea, changes of the ST segment, T wave, or QTc interval on electrocardiogram, and raised cardiac enzymes. Typical findings are disturbances of segmental contractility (apical hypokinesia or akinesia), with normal epicardial coronary arteries. The true prevalence is unknown, as the syndrome may be under-diagnosed; it is more common in postmenopausal women. There is usually a trigger in the form of physical or psychological stress. The electrocardiographic, echocardiographic, and ventriculographic changes resolve spontaneously over a variable period of time (from days to months). There are a number of pathophysiological theories, none of which has been shown to be definitive, suggesting that all of them may be involved to some extent. The prognosis is generally favourable, and recurrence is very rare.

[Delayed myocardial enhancement and diagnosis of acute coronary syndrome with normal coronarography]

Cardiac MRI in patients with acute coronary syndrome with elevated troponin levels but normal coronarography can now routinely be performed on most MR units. MRI plays an important role in this clinical setting by its ability to detect myocardial infarction in patients with normal coronarography or suggest a different, potentially severe, alternate diagnosis such as myocarditis or takotsubo cardiomyopathy.

Transient left ventricular dysfunction syndrome: patho-physiological bases through nuclear medicine imaging

BACKGROUND

Takotsubo cardiomyopathy (TTC) is a novel heart disease, mimicking acute myocardial infarction. The term "transient left ventricular dysfunction syndrome" (TLVDS) seems to be more appropriate since variant forms of TTC sparing apical segments (mid-ventricular ballooning syndrome (MVBS) and inverted TTC) have been described. Patho-physiological bases of TLVDS remain poorly understood and its optimal management is until now empirical. Our aim was to characterize patho-physiological mechanisms of TLVDS by means of nuclear medicine procedures and to discuss the clinical usefulness of isotopic imaging for a non-invasive diagnosis of TLVDS.

METHODS AND RESULTS

During the sub acute phase, eighteen patients with TLVDS (13 TTC and 5 MVBS) underwent myocardial (99m)Tc-tetrofosmin or (201)Thallium Gated Single Photon Emission Computed Tomography (G-SPECT) (n=11), (123)I-mIBG SPECT (n=8) and (18)F-FDG Gated Positron Emission Tomography (G-PET) (n=15), assessing respectively LV perfusion, sympathetic innervation and glucose metabolism. Hypocontractile LV segments were characterized by normal perfusion but reduced uptake of (18)F-FDG and (123)I-mIBG. Topography and extent of metabolic defects and innervation abnormalities were largely overlapping. Follow-up (123)I-mIBG SPECT and (18)F-FDG G-PET were performed in selected patients showing rapid normalization of LV motion and progressive improvement of both glucose metabolism and sympathetic innervation.

DISCUSSION

With the hypothesis of neurogenic stunned myocardium as the central causative mechanism of TLVDS, (123)I-mIBG SPECT seems to be the most specific diagnostic technique. Sympathetic function and glucose metabolism seem to be strictly correlated in the hypocontractile LV segments. Finally, our results underline the role of nuclear imaging in the setting of patho-physiological mechanisms of TLVDS.

Case of transient mid-ventricular ballooning syndrome with a rapid and uncommon recovery

A 60-year-old woman presented with acute pulmonary edema followed by cardiopulmonary arrest due to idiopathic ventricular fibrillation. Owing to immediate cardioversion, her electrocardiogram showed sinus rhythm and echocardiography did not show any wall motion abnormalities. The next day, echocardiographic re-examination was characterized by akinesis of both apical and mid segments of the left ventricle. One hour later, subsequently performed coronary angiography revealed non-occlusive coronary artery disease, but left ventriculography demonstrated only akinesis of mid-ventricular segment with hypercontractile other segments. Further echocardiographic investigation on the following day showed total resolution of left ventricular wall motion abnormalities. The diagnosis of mid-ventricular ballooning syndrome was made according to the findings of left ventriculography. In this case, the time course changes of both patient's pathophysiological condition and echocardiographic wall motion from the onset to recovery are rapid and uncommon.

Midventricular form of takotsubo cardiomyopathy as a recurrence 1 year after typical apical ballooning: a case report

Takotsubo cardiomyopathy was first described in Japan and is characterized by transient left ventricular apical ballooning in the absence of a significant coronary artery disease.Caused by the clinical presentation including chest pain, electrocardiographic changes and elevated myocardial markers this syndrome is frequently misdiagnosed as an acute coronary syndrome. Recurrences of Takotsubo Cardiomyopathy, especially in variant regions of the left ventricle are rareWe describe a midventricular form of Takotsubo Cardiomyopathy as a recurrence 1 year after typical apical ballooning.

Catecholamines may play an important role in the pathogenesis of transient mid- and basal ventricular ballooning syndrome

The exact pathogenesis of transient mid- and basal ventricular ballooning, a new variant of transient left ventricular (LV) ballooning, remains unknown. We report two cases of transient mid- and basal ventricular ballooning associated with catecholamines. These cases suggest that catecholamine-mediated myocardial dysfunction might be a potential mechanism of this syndrome.

Magnetic resonance reveals long-term sequelae of apical ballooning syndrome

BACKGROUND

The presence of small areas of necrosis has been occasionally reported immediately following apical ballooning syndrome (ABS). However, their persistence at later stages and impact on long-term prognosis are currently unknown.

METHODS

Twenty consecutive patients admitted for ABS between 2004 and 2007 were prospectively evaluated. Demographic, clinical, angiographic, and echocardiographic data were collected during hospital admission. At a mean of 11+/-9 months follow-up, a contrast enhanced cardiac magnetic resonance (ce-CMR) study was performed in 17 cases. The presence of hyperenhancement on ce-CMR images, reflecting irreversible myocardial damage, was recorded by two independent observers.

RESULTS

Two of 3 patients with hyperenhancement on ce-CMR images presented in worse condition, including pulmonary edema or cardiogenic shock, compared to just 2 of 14 patients without hyperenhancement (p=0.052). Segmental wall motion substantially improved in both of those cases; the third patient continued to have hypokinesis in a segment showing hyperenhancement. Segmental wall motion also significantly improved in all patients with no hyperenhancement. At a mean of 20+/-12 months follow-up, no deaths or major adverse cardiac events were documented among patients with or without hyperenhancement.

CONCLUSIONS

Despite segmental wall motion recovery, an area of irreversible myocardial damage can sometimes be identified long after ABS. However, in this limited series of patients, the presence of scar, even when presenting with heart failure and a higher troponin release, was not associated with adverse long-term outcomes as compared to patients with intact myocardium.

Irukandji syndrome, catecholamines, and mid-ventricular stress cardiomyopathy

We present here the first reported case of mid-ventricular stress cardiomyopathy secondary to 'Irukandji syndrome', following envenomisation from a jellyfish. Carukia barnesi is a cubozoan or box jellyfish found in Far North Queensland, Australia prevalent during the warmer months of the year. It has been associated with 'Irukandji syndrome' as characterized by a sympathetic overdrive secondary to an excess of endogenous catecholamines release. There have been previous cases of sudden onset of left ventricular dysfunction and jellyfish. The author believes that this case is important because it highlights the possible association between the sudden release in catecholamines and stress cardiomyopathy.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Transient left midventricular ballooning without apical involvement

We present a case of a 51-years-old woman with acute chest pain and ECG showing diffuse ST segment deviation who was transferred to our hospital to perform an urgent coronary angiography. There were no significant obstructions and left ventriculography (LVG) showed a midventricular ballooning without the apical dysynergy described previously in Tako-Tsubo or stress-induced cardiomyopathy. She had a favourable hospital course and a new LVG at 30 days showed total normalization of contractility. This recently described new pattern of transient left ventricular dysfunction was probably induced by a great mental stress state that the patient described in the preceding 24-48 h and the intrinsic mechanism could be a direct catecholamine myocardial damage or a microcirculation spasm.

Transient mid-ventricular ballooning syndrome complicated by syncope: a variant of tako-tsubo cardiomyopathy

Tako-tsubo cardiomyopathy, also called transient left ventricular apical ballooning, is a clinical entity first described in Japan. This syndrome is triggered by emotional or physical stress and mimics an acute coronary syndrome, although the coronary arteries are essentially normal. Recently, several reports have described variant forms of tako-tsubo cardiomyopathy, such as inverted tako-tsubo and mid-ventricular ballooning cardiomyopathy. We describe a case herein of an 87-year-old woman who presented a variant form of tako-tsubo cardiomyopathy complicated by syncope. Our findings may contribute to an elucidation of the mechanism underlying tako-tsubo cardiomyopathy.

2- and 3-Dimensional Echocardiographic Analysis of an Unusual Transient Apical Ballooning

We report the clinical case of a 60-year-old woman who referred to our hospital for the occurrence of typical chest pain during mild effort. At admission, the electrocardiogram showed S-T segment elevation from V(3) to V(6), and an increase in troponin I level (11.4 ng/mL). Echocardiogram showed midapical segment akinesia with depressed ejection fraction (30%). Basal segments were hypercontractile and there was evidence of dynamic obstruction of the left ventricle with an end-systolic peak gradient of 65 mm Hg. Results of emergency coronary arteriography were normal and left ventricular angiography confirmed the midapical akinesia and hypercontractility of the basal segments. Serial 2- and 3-dimensional Doppler echocardiographic examinations were performed. Regression of left ventricular outflow tract obstruction was soon detected (day 3). Fifteen days after admission, 2- and 3-dimensional echocardiography showed a complete regression of both apical ballooning and wall-motion abnormalities with an improvement in overall systolic function. Segmental volumetric analysis allowed accurate assessment of regional volumes and ejection fraction, which were indicative for a progressive reverse remodeling. Regression of wall-motion abnormalities was expressed by a normalization in regional ejection fraction curves at 15 days.

Takotsubo cardiomyopathy

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

The clinical features of transient left ventricular nonapical ballooning syndrome: comparison with apical ballooning syndrome

BACKGROUND

Recently, several cases of atypical left ventricular (LV) ballooning syndrome without involvement of the LV apex have been reported. However, there has been no assessment of the clinical features of this novel presentation or comparison with the typical transient LV apical ballooning syndrome.

METHODS

We evaluated 47 patients diagnosed with transient LV ballooning syndrome. The diagnostic criteria were (1) transient akinesia/dyskinesia beyond a single major coronary artery vascular distribution, (2) absence of significant coronary artery disease on coronary angiograms, and (3) new electrocardiographic changes.

RESULTS

Thirty-one patients showed classic LV apical ballooning, and 16 showed atypical LV ballooning without involvement of the LV apex (nonapical ballooning). Clinical presentations and inhospital courses of illness were mostly similar among patients with nonapical ballooning (group NA) and patients with apical ballooning (group A). However, on admission, there were fewer patients with cardiogenic shock or pulmonary edema in group NA than in group A (19% vs 48%, P = .048). Group NA patients were relatively younger than group A patients (median ages 58 vs 70 years, P = .02), and fewer patients had coronary risk factors in group NA than in group A (38% vs 77%, P = .01). On electrocardiogram, T-wave inversion was noted less frequently in the NA group than in the A group (69% vs 97%, P = .01).

CONCLUSIONS

Transient LV nonapical ballooning syndrome and classic LV apical ballooning syndrome may be different manifestations of a single syndrome. They appear to have differences in the severity of heart failure, in patient characteristics, and in electrocardiographic change.

A report of 2 cases of transient mid-ventricular ballooning

Takotsubo cardiomyopathy is now well recognized not only in Japan but also in Western countries. In the present case report, we describe 2 cases of a variant type of Takotsubo cardiomyopathy showing transient ballooning of the mid-portion of the left ventricle.

A case of transient left mid ventricular ballooning

We describe a case of an 85-year-old woman who presented with chest pain after a crisis of bronchial asthma. On admission, the electrocardiogram showed ST-segment elevation in leads II, III, and aVF. Peak troponin I level was 3.0 ng/dl (normal value <0.4 ng/dl). Angiography demonstrated ballooning of the mid portion of the left ventricle without involvement of the apex. No obstructive epicardial coronary artery disease was present. After 8 days, left ventricular wall motion improved and returned completely to normal at 1-month echocardiographic follow-up.

Takotsubo cardiomyopathy — A new variant and widening disease spectrum

Classic takotsubo cardiomyopathy had left ventricular apical ballooning. Variants with mid-ventricular ballooning without involvement of the apex have been described. We describe a new variant of takotsubo cardiomyopathy where apical contraction was preserved while the rest of the ventricle was dyskinetic.

A Chinese patient with severe takotsubo cardiomyopathy

A 66-year-old woman presented with acute pulmonary edema followed by cardiogenic shock. Emergency left ventriculography demonstrated typical apical ballooning of takotsubo cardiomyopathy. Coronary angiogram and intravascular ultrasonography did not reveal significant coronary artery disease. Within days, the left ventricular systolic function returned to normal.

Myocardial scintigraphy in a patient with transient mid-ventricular ballooning cardiomyopathy: Case report

We report a case of a 51-year-old man with transient mid-ventricular ballooning cardiomyopathy. Left ventriculography demonstrated mid-ventricular ballooning and akinesis with hypercontractile apical and basal segments. Iodine-123-beta-methyl-p-iodophenyl-penta-decanoic acid myocardial scintigraphy showed decreased uptake in the mid-ventricle, corresponding to the mid-ventricular akinetic region. This is the first report of a transient mid-ventricular ballooning cardiomyopathy observed by not only left ventriculography but myocardial scintigraphy.

Myocardial infarction with normal coronary arteries: a conundrum with multiple aetiologies and variable prognosis: an update

The existence of myocardial infarction despite angiographically normal coronary arteries was recognized more than 30 years ago. Since then, various series of such patients have been described, but the aetiology and pathogenesis of the condition are still a source of debate. Evidence exists for a role of coronary vasospasm, thrombosis, embolization and inflammation, per se or combined, in determining the occurrence of myocardial infarction in the presence of angiographically normal coronary arteries. Endothelial dysfunction, possibly superimposed to nonangiographically evident atherosclerosis, may be an underlying common feature predisposing to the acute event. Additionally, myocarditis may explain some of these occurrences. Myocardial infarction with normal coronary arteries is therefore likely the result of multiple pathogenetic mechanisms. Although most reports emphasize the good prognosis of this condition, in general much better than myocardial infarction with coronary artery disease, prognosis is likely variable according to the underlying mechanism. This review summarizes current knowledge on this condition and examines areas of recent progress.

Transient stress-induced cardiomyopathy with an "inverted takotsubo" contractile pattern

We describe a patient who had transient cardiomyopathy with akinesia of the basal portions of the left ventricle and hyperkinesia of the apex triggered by alcoholic pancreatitis. This case seems to confirm recent publications suggesting a new or variant clinical entity with a clinical presentation similar to that of Takotsubo cardiomyopathy but with an Inverse left ventricular contractile pattern ("Inverted Takotsubo"). This entity could provide clues to the underlying pathophysiology of these syndromes of acute heart injury.

Transient midventricular ballooning syndrome: a new variant

We describe a new variant of transient left ventricular (LV) ballooning in North American Caucasian patients in which only the midventricle is affected. The patients described in this case series initially presented with emotional or physical stress and had similarities to transient apical ballooning syndrome; however, this variant is unique in that the transient ballooning involves the midventricle with hypercontractility of the apical and basal segments. The presentation, clinical features, and transient nature of the reported cases in this series are similar to transient LV apical ballooning and suggest a shared pathophysiologic etiology. Sparing of the apical segment with involvement of midventricle only supports etiologies not related to an epicardial coronary artery distribution. Although the pathophysiologic mechanism of the transient ventricular ballooning syndromes and other cases of catecholamine-associated transient ventricular dysfunction are not well understood, the emergence of this new variant raises further questions in the understanding of the "brain-heart" relationship.