Ultra-fast Tako-Tsubo cardiomyopathy after local anesthesia for eye surgery: Are we missing the submerged bottom of the iceberg?

Perioperative management of Takotsubo cardiomyopathy: an overview

Resembling the morphology of Japanese polyp vessels, the classic form of Takotsubo cardiomyopathy is characterized by the presence of systolic dysfunction of the mid-apical portion of the left ventricle associated with basal hyperkinesia. It is believed that this may be due to a higher density of β-adrenergic receptors in the context of the apical myocardium, which could explain the greater sensitivity of the apex to fluctuations in catecholamine levels.The syndrome is precipitated by significant emotional stress or acute severe pathologies, and it is increasingly diagnosed during the perioperative period. Indeed, surgery, induction of general anaesthesia and critical illness represent potential harmful trigger of stress cardiomyopathy. No universally accepted guidelines are currently available, and, generally, the treatment of TTS relies on health care personal experience and/or local practice. In our daily practice, anaesthesiologists can be asked to manage patients with the diagnosis of new-onset Takotsubo before elective surgery or an emergent surgery in a patient with a concomitant stress cardiomyopathy. Even more, stress cardiomyopathy can arise as a complication during the operation.In this paper, we aim to provide an overview of Takotsubo syndrome and to discuss how to manage Takotsubo during surgery and in anaesthesiologic special settings.

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

PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Fast ‘wandering’ Takotsubo syndrome: atypical mixed evolution from apical to mid-ventricular ballooning

We report the case of a 53-year-old woman admitted for typical chest pain and a diagnosis of Takotsubo syndrome (TTS). Initial echocardiographic presentation was characterized by apical and mid-ventricular akinesis and basal hyper-kinesis. Unexpectedly, later after admission, echocardiography showed recovered apical akinesis with an apparent ‘migration’ of systolic dysfunction to mid-ventricular segment and hyper-kinesis of apical and basal segments. One week after admission, left ventricular contractility completely recovered and cardiac magnetic resonance imaging did not show signs of subendocardial late-enhancement and myocardial edema. Cases of TTS may therefore occasionally rapidly ‘wander’ within left ventricular segments, raising doubts over the so far used classification of left ventricular patterns of ballooning in subjects with TTS (typical/atypical). Apparently, different patterns can rapidly evolve into each other. The absence of late-enhancement at cardiac magnetic resonance imaging could hypothetically identify rapidly ‘wandering’ cases.

Drug-Induced Takotsubo Cardiomyopathy

BACKGROUND

The most plausible hypothesis for takotsubo cardiomyopathy (TCM) is a catecholamine surge. Direct administration of catecholamines or medications causing catecholamine surge is frequently used in clinical practice.

METHODS

A Medline/PubMed database search was conducted for case reports or series of drug-induced TCM. All reported cases of drug-induced TCM were systemically identified and analyzed.

RESULTS

We identified 157 cases of drug-induced TCM. Fifty-seven (36.3%) cases were related to the administration of exogenous catecholamines. In 50 (31.9%) other cases, there was potential adrenergic effect. This included drugs with adrenergic vasoconstriction properties (3.2%), hyperadrenergic state due to alcohol or opioid withdrawal (7.7%), inhibitors of catecholamine reuptake (14.7%), anaphylactic reaction that is accompanied by catecholamine release (3.2%), and psychological or somatic stress coinciding with the administration of a drug that was thought to be the culprit (3.2%). Overall, 68.2% of these drug-induced TCM cases were catecholamine related. In 14 (8.9%) cases, the likely etiology of cardiomyopathy was chemotherapy-induced coronary vasospasm.

CONCLUSION

Our systematic review showed that over two-thirds of drug-induced TCM cases were due to direct or indirect catecholamine stimulation. The lowest effective dose and shortest duration of catecholamines should be utilized, and alternative therapies should be considered if feasible.

Therapy of stress (takotsubo) cardiomyopathy: present shortcomings and future perspectives

Several therapeutic options are available for the treatment of the acute phase of stress cardiomyopathy, pharmacological (β-blockers, diuretics, anticoagulants, antiarrhythmics, noncatecholamine inotropics [levosimendan]), and nonpharmacological (intra-aortic balloon pumping, extracorporeal membrane oxygenation), according to the wide possible clinical presentation and course of the disease. However, there is a gap in evidence, and very few data come from randomized and adequately powered studies. Some evidence supports the use of β-blockers, in particular with a short half-life, in the case of left ventricular outflow tract obstruction, and angiotensin-converting enzyme inhibitors in secondary prevention. Future perspectives include the study of genetic basis of stress cardiomyopathy, role of miRNA and neurovegetative modulation. Randomized studies, however, are surely warranted.

Safety and feasibility of levosimendan administration in takotsubo cardiomyopathy: a case series

BACKGROUND

Levosimendan is a noncatecholamine inotrope that does not increase oxygen consumption, utilized for the treatment for acute heart failure with left ventricular (LV) systolic dysfunction. Its use in takotsubo cardiomyopathy (TTC), a disease that contraindicates the use of catecholamine inotropes, is not well known.

METHODS

We prospectively analyzed 13 consecutive patients with TTC, low ejection fraction (EF) (<35%), and additional Mayo Clinic risk factors who were treated with i.v. infusion of levosimendan. Clinical course of patients, electrocardiogram presentation, LV function, and adverse events at follow-up were recorded.

RESULTS

All patients showed an impaired LV function (LVEF at admission 28 ± 5%), which significantly improved at discharge (51 ± 8%, P < 0.001). Mean hospital stay was 10 ± 4 days. Troponin levels at admission were directly related to length of hospitalization (r = 0.6, P < 0.001). Male gender (relative risk (RR) 1.85, P < 0.05), physical stress (RR 1.90, P < 0.05), ST elevation at ECG (RR 1.87, P < 0.05), and absence of chest pain (RR 2.23, P < 0.01) were found to be the predictors of longer hospital stay. Only 15% of subjects had adverse events during hospital stay; two patients incurred noncardiovascular death at follow-up. Age was the only predictor of adverse event at follow-up (RR 2.13, P < 0.05).

CONCLUSIONS

The use of levosimendan may be safe and feasible in patients with TTC. Randomized studies are warranted to further confirm these preliminary results.