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von Mackensen JKR, Shazly AE, Schoenrath F, Kempfert J, Starck CT, Potapov EV, Jacobs S, Falk V, Wert L. Successful treatment of cardiogenic shock due to Takotsubo syndrome with implantation of a temporary microaxial left ventricular assist device in transaxillary approach. J Cardiothorac Surg 2023; 18:343. [PMID: 38012790 PMCID: PMC10683305 DOI: 10.1186/s13019-023-02459-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 11/15/2023] [Indexed: 11/29/2023] Open
Abstract
OBJECTIVES Cardiogenic shock (CS) can occur in patients with Takotsubo syndrome (TTS). As TTS has received increasing attention and has been more closely researched, several aspects of the pathogenesis have been identified, particularly that an excessive release of catecholamines plays an important role. Nevertheless, evidence on specific therapy concepts is still lacking. As a result, TTS with severe hemodynamic instability and low cardiac output creates unique challenges, and mechanical circulatory support is needed with as few inotropic drugs as possible. METHODS We present a 77-year-old female patient who underwent minimally invasive surgical mitral valve replacement. After an uneventful course, the patient developed acute heart failure eleven days after surgery. Transthoracic echocardiography (TTE) revealed a new onset of TTS. The patient needed left ventricular venting and full haemodynamic flow. We successfully implanted a microaxial left ventricular assist device (Impella 5.5) using the transaxillary approach. The haemodynamic situation stabilised immediately. The patient was weaned and the Impella 5.5 was explanted after five days. CONCLUSION We present the first-in-man implantation of a transaxillary Impella 5.5 in a patient with TTS. The patient benefitted from Impella 5.5 therapy with full haemodynamic support and venting of the left ventricle.
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Affiliation(s)
- Johanna K R von Mackensen
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Ahmed El Shazly
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Schoenrath
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- DZHK (German Center for Cardiovascular Research) partner site Berlin, Berlin, Germany
| | - Joerg Kempfert
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- DZHK (German Center for Cardiovascular Research) partner site Berlin, Berlin, Germany
| | - Christoph T Starck
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- DZHK (German Center for Cardiovascular Research) partner site Berlin, Berlin, Germany
| | - Evgenij V Potapov
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- DZHK (German Center for Cardiovascular Research) partner site Berlin, Berlin, Germany
| | - Stephan Jacobs
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- DZHK (German Center for Cardiovascular Research) partner site Berlin, Berlin, Germany
| | - Volkmar Falk
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
- DZHK (German Center for Cardiovascular Research) partner site Berlin, Berlin, Germany
- Department of Cardiothoracic Surgery, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
- Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
| | - Leonhard Wert
- Department of Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
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Waksman R, Pahuja M, van Diepen S, Proudfoot AG, Morrow D, Spitzer E, Nichol G, Weisfeldt ML, Moscucci M, Lawler PR, Mebazaa A, Fan E, Dickert NW, Samsky M, Kormos R, Piña IL, Zuckerman B, Farb A, Sapirstein JS, Simonton C, West NEJ, Damluji AA, Gilchrist IC, Zeymer U, Thiele H, Cutlip DE, Krucoff M, Abraham WT. Standardized Definitions for Cardiogenic Shock Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium (SHARC). Circulation 2023; 148:1113-1126. [PMID: 37782695 PMCID: PMC11025346 DOI: 10.1161/circulationaha.123.064527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 10/04/2023]
Abstract
The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies, industry, and payers, convened to develop pragmatic consensus definitions useful for the evaluation of clinical trials enrolling patients with cardiogenic shock, including trials evaluating mechanical circulatory support devices. Several in-person and virtual meetings were convened between 2020 and 2022 to discuss the need for developing the standardized definitions required for evaluation of mechanical circulatory support devices in clinical trials for cardiogenic shock patients. The expert panel identified key concepts and topics by performing literature reviews, including previous clinical trials, while recognizing current challenges and the need to advance evidence-based practice and statistical analysis to support future clinical trials. For each category, a lead (primary) author was assigned to perform a literature search and draft a proposed definition, which was presented to the subgroup. These definitions were further modified after feedback from the expert panel meetings until a consensus was reached. This manuscript summarizes the expert panel recommendations focused on outcome definitions, including efficacy and safety.
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Affiliation(s)
- Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W.)
| | - Mohit Pahuja
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City (M.P.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK (A.G.P.)
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Germany (A.G.P.)
| | - David Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.M.)
| | - Ernest Spitzer
- Cardialysis, Rotterdam, The Netherlands (E.S.)
- Cardiology Department, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands (E.S.)
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington Harborview Center, Seattle (G.N.)
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (M.L.W.)
| | - Mauro Moscucci
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital Research Institute, Canada (P.R.L.)
- McGill University Health Centre, Montreal, Canada (P.R.L.)
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (P.R.L.)
| | - Alexandre Mebazaa
- Université Paris Cité, Department of Anesthesiology and Critical Care Medicine, Hôpital Lariboisière, France (A.M.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (E.F.)
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (N.W.D.)
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (M.S.)
| | - Robert Kormos
- Global Medical Affairs Heart Failure, Abbott Laboratories, Austin, TX (R.K.)
| | - Ileana L Piña
- Division of Cardiology, Thomas Jefferson University, Philadelphia, PA (I.L.P.)
| | - Bram Zuckerman
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Andrew Farb
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - John S Sapirstein
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | | | | | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D.)
| | - Ian C Gilchrist
- Department of Interventional Cardiology/Heart and Vascular Institute, Penn State Health/Hershey Medical Center (I.C.G.)
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Germany (H.T.)
- Leipzig Heart Science, Germany (H.T.)
| | - Donald E Cutlip
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA (D.E.C.)
| | - Mitchell Krucoff
- Department of Medicine, Duke University School of Medicine, Durham, NC (M.K.)
| | - William T Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University College of Medicine/Ohio State University Wexner Medical Center, Columbus (W.T.A.)
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Abstract
Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4-5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.
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Affiliation(s)
| | | | - Helen Melita
- 69106Central Laboratories, Onassis Cardiac Surgery Center, Athens, Greece
| | - Antonis S Manolis
- First Department of Cardiology, Athens University School of Medicine, Athens, Greece
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Santoro F, Núñez Gil IJ, Stiermaier T, El-Battrawy I, Moeller C, Guerra F, Novo G, Arcari L, Musumeci B, Cacciotti L, Mariano E, Romeo F, Cannone M, Caldarola P, Giannini I, Mallardi A, Leopizzi A, Vitale E, Montisci R, Meloni L, Raimondo P, Di Biase M, Almendro-Delia M, Sionis A, Uribarri A, Akin I, Thiele H, Eitel I, Brunetti ND. Impact of intra-aortic balloon counterpulsation on all-cause mortality among patients with Takotsubo syndrome complicated by cardiogenic shock: results from the German-Italian-Spanish (GEIST) registry. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead003. [PMID: 36789137 PMCID: PMC9921723 DOI: 10.1093/ehjopen/oead003] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 12/15/2022] [Accepted: 01/20/2023] [Indexed: 01/26/2023]
Abstract
Aims Takotsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction and can be complicated by cardiogenic shock (CS). However, few data are available on optimal care in TTS complicated by CS. Aim of this study was to evaluate short- and long-term impact of intra-aortic balloon pumping (IABP) on mortality in this setting. Methods and results In a multi-centre, international registry on TTS, 2248 consecutive patients were enrolled from 38 centres from Germany, Italy, and Spain. Of the 2248 patients, 212 (9.4%) experienced CS. Patients with CS had a higher prevalence of diabetes (27% vs. 19%), male sex (25% vs. 10%), and right ventricular involvement (10% vs. 5%) (P < 0.01 in all cases). Forty-three patients with CS (20% of 212) received IABP within 8 h (interquartile range 4-18) after admission. No differences in terms of age, gender, cardiovascular risk factors, and admission left ventricular ejection fraction were found among patients with and without IABP. There were no significant differences in terms of 30-day mortality (16% vs. 17%, P = 0.98), length of hospitalization (18.9 vs. 16.7 days, P = 0.51), and need of invasive ventilation (35% vs. 41%, P = 0.60) among two groups: 30-day survival was not significantly different even after propensity score adjustment (log-rank P = 0.73). At 42-month follow-up, overall mortality in patients with CS and TTS was 35%, not significantly different between patients receiving IABP and not (37% vs. 35%, P = 0.72). Conclusions In a large multi-centre observational registry, the use of IABP was not associated with lower mortality rates at short- and long-term follow-up in patients with TTS and CS.
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Affiliation(s)
| | | | - Thomas Stiermaier
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM) University of Heidelberg, Mannheim, Germany,German Center for Cardiovascular Research, Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Christian Moeller
- University Heart Center Lübeck, Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital ‘Umberto I—Lancisi—Salesi’, Ancona, Italy
| | - Giuseppina Novo
- Biomedical Department of Internal Medicine and Medical Specialties, University of Palermo, Cardiology Unit, Palermo, Italy
| | - Luca Arcari
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Beatrice Musumeci
- Cardiology, Clinical and Molecular Medicine Department, Faculty of Medicine and Psychology, Sapienza University of Rome, Rome, Italy
| | - Luca Cacciotti
- Institute of Cardiology, Madre Giuseppina Vannini Hospital, Rome, Italy
| | - Enrica Mariano
- Division of Cardiology, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Romeo
- Division of Cardiology, University of Rome Tor Vergata, Rome, Italy
| | | | | | - Irene Giannini
- German Center for Cardiovascular Research, Partner Site, Heidelberg-Mannheim, Mannheim, Germany
| | - Adriana Mallardi
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto n.1, 71122 Foggia, Italy
| | - Alessandra Leopizzi
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto n.1, 71122 Foggia, Italy
| | - Enrica Vitale
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto n.1, 71122 Foggia, Italy
| | - Roberta Montisci
- San Giovanni di Dio Hospital, University of Cagliari, Cagliari, Italy
| | - Luigi Meloni
- San Giovanni di Dio Hospital, University of Cagliari, Cagliari, Italy
| | - Pasquale Raimondo
- Department of cardiac Anesthesia and Intensive care unit, Santa Maria Hospital, GVM Care and Research, Bari, Italy
| | - Matteo Di Biase
- Department of Medical and Surgical Sciences, University of Foggia, Viale Pinto n.1, 71122 Foggia, Italy
| | | | - Alessandro Sionis
- Unidad de Cuidados Intensivos Cardiológicos, Servicio de Cardiología, Hospital de Sant Pau, Instituto de Investigación Biomédica Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Aitor Uribarri
- Cardiology Department, Hospital Clínico Valladolid, Valladolid, Spain
| | - Ibrahim Akin
- First Department of Medicine, Faculty of Medicine, University Medical Centre Mannheim (UMM) University of Heidelberg, Mannheim, Germany
| | - Holger Thiele
- Department of Internal Medicine/Cardiology, Heart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany
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Tehrani BN, Epps KC, Sherwood MW. Unloading a broken heart: Impella support for Takotsubo syndrome complicated by cardiogenic shock. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2022; 40:120-122. [DOI: 10.1016/j.carrev.2022.04.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2022] [Accepted: 04/26/2022] [Indexed: 12/25/2022]
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Benak A, Sramko M, Janek B, Zelizko M, Kautzner J. Successful Treatment of Cardiogenic Shock Due to Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction and Acute Mitral Regurgitation by Impella CP. Cureus 2022; 14:e23168. [PMID: 35433143 PMCID: PMC9008599 DOI: 10.7759/cureus.23168] [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] [Accepted: 02/04/2022] [Indexed: 11/05/2022] Open
Abstract
Treatment of Takotsubo cardiomyopathy (TC) with left ventricular outflow obstruction (LVOTO) remains challenging. Mechanical circulatory support (MCS) as a bridge to myocardial recovery is sometimes the only therapeutic option, even though the optimal type of MCS is still under debate. This report describes a case of TC complicated by cardiogenic shock due to LVOTO and severe mitral regurgitation that was successfully treated with the latest generation percutaneous pump Impella CP®.
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Montone RA, La Vecchia G, Buono MGD, Abbate A, Sanna T, Pedicino D, Niccoli G, Antonelli M, Crea F. Takotsubo Syndrome in Intensive Cardiac Care Unit: Challenges in Diagnosis and Management. Curr Probl Cardiol 2021; 47:101084. [PMID: 34942270 DOI: 10.1016/j.cpcardiol.2021.101084] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 12/15/2021] [Indexed: 01/02/2023]
Abstract
Takotsubo syndrome (TTS) is an acute reversible form of myocardial dysfunction that is often associated with serious adverse in-hospital complications, including acute heart failure, cardiogenic shock and life-threatening arrythmias. In the absence of randomized clinical trials, its management in the acute phase is based on empirical supportive pharmacological and non-pharmacological measures.In this review article, we aimed at providing an overview of the acute clinical manifestations of patients presenting with TTS, highlighting the predictors of a worse short-term outcome, along with the challenges in therapeutic management of TTS-related complications in the acute care setting.
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Affiliation(s)
- Rocco Antonio Montone
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Giulia La Vecchia
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Marco Giuseppe Del Buono
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond
| | - Antonio Abbate
- Wright Center for Clinical and Translational Research, Virginia Commonwealth University, Richmond
| | - Tommaso Sanna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Daniela Pedicino
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giampaolo Niccoli
- Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Massimo Antonelli
- Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Anesthesiology and Intensive Care Medicine, Catholic University of The Sacred Heart, Fondazione 'Policlinico Universitario A. Gemelli' IRCCS, Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Nishikawa R, Nagano N, Kokubu N, Hashimoto K, Nakata J, Kishiue N, Takahashi R, Otomo S, Tsuchihashi K, Yano T. Favorable Effects of Impella on Takotsubo Syndrome Complicated with Cardiogenic Shock. Int Heart J 2021; 62:1430-1435. [PMID: 34789645 DOI: 10.1536/ihj.21-299] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Reportedly, approximately 9.9%-12.4% of patients with Takotsubo syndrome (TTS) are complicated with cardiogenic shock (CS) and its prognosis remains poor even with the support of conventional mechanical circulatory assist devices including intra-aortic balloon pumping and venoarterial extracorporeal membrane oxygenation. Impella, a novel percutaneous left ventricular assist device, provides strong circulatory support together with the unloading of the left ventricle, and it is theoretically a promising mechanical circulatory assist device for TTS. In this case study, we report four consecutive patients with TTS complicated with CS who were successfully resuscitated using the Impella support.
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Affiliation(s)
- Ryo Nishikawa
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Nobutaka Nagano
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Nobuaki Kokubu
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Kanae Hashimoto
- Department of Clinical Engineering, Sapporo Medical University School of Medicine
| | - Jun Nakata
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Naohiro Kishiue
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Ryo Takahashi
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Shunsaku Otomo
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
| | - Kazufumi Tsuchihashi
- Division of Health Care Administration and Management, Sapporo Medical University School of Medicine
| | - Toshiyuki Yano
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine
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9
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Impella mechanical circulatory support for Takotsubo syndrome with shock: A retrospective multicenter analysis. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2021; 40:113-119. [PMID: 34916157 DOI: 10.1016/j.carrev.2021.11.018] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2021] [Revised: 11/14/2021] [Accepted: 11/15/2021] [Indexed: 01/29/2023]
Abstract
OBJECTIVES To analyze the characteristics and outcome of Impella mechanical circulatory support (MCS) for Takotsubo syndrome (TS) with cardiogenic shock. BACKGROUND TS is an acute heart failure syndrome characterized by transient severe reduction of left ventricular (LV) systolic function, with cardiogenic shock occurring in around 10% of patients. Since inotropes should be avoided due to their role in TS pathogenesis and aggravation of LV outflow tract obstruction, the use of MCS as treatment is a viable treatment option, however, studies are lacking. METHODS The catheter-based ventricular assist device (cVAD) registry and local MCS databases were screened for TS patients with cardiogenic shock (TS-CS) supported with an Impella percutaneous ventricular assist device (pVAD). Patient and treatment characteristics and in-hospital outcomes were retrospectively analyzed. RESULTS At 10 US and European centers, 16 TS-CS patients supported with an Impella pVAD were identified between December 2013 and May 2018 (mean age, 61.8 ± 15.5 years; 87.5% women). LV ejection fraction (LVEF) at presentation was severely reduced (mean, 19.4 ± 8.3%). Prior to MCS, 13 patients (81.3%) were mechanically ventilated, 4 patients (25.0%) had been resuscitated, and mean serum lactate was 4.7 ± 3.5 mmol/L. Mean duration of Impella support was 1.9 ± 1.0 days (range, 1-4 days). Thirteen patients (81.3%) survived to discharge, and all survivors experienced cardiac recovery with significant improvement of LVEF at discharge compared to baseline (20.4 ± 8.8 vs. 52.9 ± 12.0, P < 0.001). CONCLUSIONS This is the first series of TS-CS patients supported with an Impella pVAD. Mortality was low, and LV systolic function recovered in all survivors. Prospective studies of Impella support in this special condition are warranted.
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10
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Madias JE. Takotsubo Cardiomyopathy: Current Treatment. J Clin Med 2021; 10:3440. [PMID: 34362223 PMCID: PMC8347171 DOI: 10.3390/jcm10153440] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/21/2021] [Accepted: 07/26/2021] [Indexed: 02/07/2023] Open
Abstract
Management of takotsubo syndrome (TTS) is currently empirical and supportive, via extrapolation of therapeutic principles worked out for other cardiovascular pathologies. Although it has been emphasized that such non-specific therapies for TTS are consequent to its still elusive pathophysiology, one wonders whether it does not necessarily follow that the absence of knowledge of TTS' pathophysiological underpinnings should prevent us for searching, designing, or even finding, therapies efficacious for its management. Additionally, it is conceivable that therapy for TTS may be in response to pathophysiological/pathoanatomic/pathohistological consequences (e.g., "myocardial stunning/reperfusion injury"), common to both TTS and coronary artery disease, or other cardiovascular disorders). The present review outlines the whole range of management principles of TTS during its acute phase and at follow-up, including considerations pertaining to the recurrence of TTS, and commences with the idea that occasionally management of TTS should consist of mere observation along the "first do no harm" principle, while self-healing is under way. Finally, some new therapeutic hypotheses (i.e., large doses of insulin infusions in association with the employment of intravenous short- and ultrashort-acting β-blockers) are being entertained, based on previous extensive animal work and limited application in patients with neurogenic cardiomyopathy and TTS.
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Affiliation(s)
- John E. Madias
- Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA; ; Tel.: +1-(718)-334-5005; Fax: +1-(718)-334-5990
- Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY 11373, USA
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Barsoum E, Elhosseiny S, Patel B, Pathak S, Patel A, Vaidya P. Successful use of the impella ventricular assist device for management of reverse Takotsubo Cardiomyopathy in the setting of acute intracranial hemorrhage. Heart Lung 2021; 50:313-315. [PMID: 33482434 DOI: 10.1016/j.hrtlng.2021.01.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 01/02/2021] [Accepted: 01/08/2021] [Indexed: 11/25/2022]
Abstract
Reverse Takotsubo Cardiomyopathy (rTTC) is a rare variant of Takotsubo Cardiomyopathy (TTC) that is characterized by hypokinesis of the base and sparing of the mid to apical wall of the left ventricle best seen on echocardiogram. Intracranial hemorrhage (ICH) has been identified as a risk factor rTTC. Nearly around 10% of the patients with TTC develop cardiogenic shock. We hereby report the successful use of the Impella Ventricular Assist Device (Impella CP®) for management of rTTC in the setting of acute ICH. Our patient is a young female who presented with loss of consciousness after an acute headache and imaging studies revealed left posterior cerebral artery aneurysm with intraventricular hemorrhage. Subsequently the patient developed hypoxia, severe hypotension and cardiac arrest. After resuscitation, an echocardiogram showed that the patient had rTTC and a cardiac angiogram showed patent coronary arteries. The Impella CP® was successfully inserted followed by immediate cerebral angiography and aneurysmal coiling. Systemic anticoagulation was started during coiling. In the next three days, the patient's left ventricular function recovered, and she was discharged home. Up to our knowledge, this is the first case report to mark the successful placement of the Impella CP® with delayed initial anticoagulation for management of rTTC. Our patient was challenging as there are no current guidelines in the management of cardiogenic shock secondary to rTTC in the setting of acute ICH.
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Affiliation(s)
- Emad Barsoum
- Department of Cardiology, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601, United States
| | - Sherif Elhosseiny
- Department of Internal Medicine, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ. 07103, United States.
| | - Brijesh Patel
- Department of Cardiology, Rutgers New Jersey Medical School, 150 Bergen Street, Newark, NJ. 07103, United States
| | - Sankalp Pathak
- Department of Cardiology, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601, United States
| | - Ankitkumar Patel
- Department of Cardiology, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601, United States
| | - Pranaychandra Vaidya
- Department of Cardiology, Hackensack University Medical Center, 30 Prospect Ave, Hackensack, NJ 07601, United States
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12
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Hanif M, Haider MA, Xi Q, Ali MJ, Khan MA. Takotsubo Cardiomyopathy Triggered by the Death of Pets (Cats): Two Case Reports. Cureus 2020; 12:e10690. [PMID: 33133855 PMCID: PMC7593210 DOI: 10.7759/cureus.10690] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Takotsubo cardiomyopathy otherwise called stress cardiomyopathy, which results in debilitating of a segment of heart muscles, is a sort of non-ischemic cardiomyopathy, set off by stress. We describe two case reports of takotsubo cardiomyopathy triggered by the significant stressful event being the death of pet cats. The rare nature of the type of stressor and the manifestation is something to be considered by healthcare providers.
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13
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Mariani S, Richter J, Pappalardo F, Bělohlávek J, Lorusso R, Schmitto JD, Bauersachs J, Napp LC. Mechanical circulatory support for Takotsubo syndrome: a systematic review and meta-analysis. Int J Cardiol 2020; 316:31-39. [PMID: 32473281 DOI: 10.1016/j.ijcard.2020.05.033] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 05/05/2020] [Accepted: 05/13/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Cardiogenic shock occurs in 10%-15% of patients with Takotsubo syndrome (TS). For several reasons catecholamines, and especially inotropes, should be avoided in TS. Temporary mechanical circulatory support (MCS) appears attractive as bridge-to-recovery, but prospective studies are lacking. Here we analyze the available literature on MCS use in patients with TS. METHODS AND RESULTS PubMed/Medline was systematically screened until December 2019. 18 studies reporting pooled data of 5629 TS patients, of whom 227 had received MCS, were considered for a qualitative synthesis. 81 articles from 2003 through 2019 reporting individual data of 93 MCS cases were included in a meta-analysis. Median age was 57 (IQR: 43-68) years, 83.9% were women, and a physical trigger could be identified in 74.1% of cases. Median left ventricular ejection fraction (LVEF) before MCS was 20% (IQR: 15-25) and comparable between groups defined by MCS device. An apical TS type was present in 76.1% of cases. The overall number of publications on MCS for TS increased over time, as did those using veno-arterial extracorporeal membrane oxygenation (V-A ECMO) and Impella, while those using intra-aortic balloon pump declined. MCS-related complications were not regularly reported. Median time on MCS was 3 (IQR: 2-7) days, with an overall survival of 94.6%. CONCLUSIONS MCS for TS-related shock is increasingly reported, with a growing use of V-A ECMO and Impella. Currently available clinical data support this approach. Prospective studies are needed to evaluate safety and efficacy of different devices as well as timing of MCS in this special patient population.
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Affiliation(s)
- Silvia Mariani
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Jannik Richter
- Cardiac Arrest Center, Advanced Heart Failure Unit, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Federico Pappalardo
- Department of Anesthesia and Intensive Care, IRCCS ISMETT, UPMC Italy, Palermo, Italy
| | - Jan Bělohlávek
- 2nd Department of Medicine, Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University and General University Hospital, Prague, Czech Republic
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Jan D Schmitto
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Johann Bauersachs
- Cardiac Arrest Center, Advanced Heart Failure Unit, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - L Christian Napp
- Cardiac Arrest Center, Advanced Heart Failure Unit, Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany.
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14
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Di Filippo C, Bacchi B, Di Mario C. Novel Aspects of Classification, Prognosis and Therapy in Takotsubo Syndrome. Eur Cardiol 2020; 14:191-196. [PMID: 31933691 PMCID: PMC6950358 DOI: 10.15420/ecr.2019.27.3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/05/2019] [Indexed: 12/20/2022] Open
Abstract
Takotsubo syndrome (TTS) can be considered a transient form of acute heart failure that mimics an acute coronary syndrome. Although many hypotheses have been formulated, the precise physiopathology of TTS remains unknown. TTS is associated with a heterogeneous clinical course, which ranges from benign to poor outcome, comprising life-threatening phenotypes. In the acute phase, TTS patients may experience complications including left ventricular outflow tract obstruction, cardiogenic shock, arrhythmias and thromboembolic events. Furthermore, after the acute episode, physiological abnormalities can persist and some patients continue to suffer cardiac symptoms. To recognise patients at higher risk earlier, many variables have been proposed and risk stratifications suggested. There is no solid evidence regarding specific therapy and the proper management of TTS patients, either in the acute phase or long term. This review describes the current knowledge regarding diagnostic criteria, prognosis and therapy in TTS.
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15
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Attisano T, Silverio A, Prota C, Briguori C, Galasso G, Citro R. Impella in Takotsubo syndrome complicated by left ventricular outflow tract obstruction and severe mitral regurgitation. ESC Heart Fail 2020; 7:306-310. [PMID: 31898420 PMCID: PMC7083498 DOI: 10.1002/ehf2.12546] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 08/21/2019] [Accepted: 09/29/2019] [Indexed: 01/30/2023] Open
Abstract
The treatment of cardiogenic shock in patients with Takotsubo syndrome (TTS) is challenging because it depends on the mechanisms leading to the haemodynamic instability. We report the case of a 70‐year‐old woman admitted for TTS complicated by cardiogenic shock. The early echocardiographic identification of left ventricular outflow tract obstruction (LVOTO) and severe mitral regurgitation (MR) prompted us to implant an Impella CP assist device as a bridge‐to‐recovery therapy. After device positioning, the haemodynamic status improved and LVOTO and severe MR disappeared. Because of the persistence of severe hypotension, the mechanical circulatory support was continued in intensive care unit and stopped only 5 days later, when intraventricular gradient spontaneously dropped. The patient was discharged after 1 week in stable conditions. Our case suggests that Impella circulating support may be a useful bridge‐to‐recovery therapeutic option in selected patients with cardiogenic shock due to TTS complicated by LVOTO and severe MR.
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Affiliation(s)
- Tiziana Attisano
- Interventional Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Angelo Silverio
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Largo Città d'Ippocrate, 84131, Salerno, Italy
| | - Costantina Prota
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Largo Città d'Ippocrate, 84131, Salerno, Italy
| | - Carlo Briguori
- Interventional Cardiology Unit, Clinica Mediterranea, Naples, Italy
| | - Gennaro Galasso
- Interventional Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Salerno, Italy
| | - Rodolfo Citro
- Cardiology Unit, Cardiovascular and Thoracic Department, University Hospital 'San Giovanni di Dio e Ruggi d'Aragona', Largo Città d'Ippocrate, 84131, Salerno, Italy
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16
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Sharma S, Polak S, George Z, LeDoux J, Sohn R, Stys A, Jeon C, Ghazzawi Y, Wood M. Management of spontaneous coronary artery dissection complicated by cardiogenic shock using mechanical circulatory support with the Impella device. Catheter Cardiovasc Interv 2019; 97:74-77. [PMID: 31876350 DOI: 10.1002/ccd.28677] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 12/16/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE The aim is to evaluate the feasibility of using mechanical circulatory support, specifically the Impella device, in spontaneous coronary artery dissection (SCAD) patients with cardiogenic shock. BACKGROUND The therapeutic options for managing SCAD complicated by cardiogenic shock are limited. Risky revascularization procedures are often necessary. METHODS This was a multicenter case series in the United States. Approximately 20 cases of Impella implantation in patients with SCAD are known. The implanting physician for each of these cases was contacted and de-identified records were requested. The records were analyzed for Impella indications, outcomes, and complications. RESULTS Records from four cases were received. All patients survived to hospital discharge and no major complications were observed. In two cases, cardiogenic shock developed in the absence of ongoing ischemia, suggesting a Takotsubo-like cardiomyopathy. In these cases, the Impella provided hemodynamic support until the patient's cardiac function recovered. CONCLUSION Although a small case series, given the scarcity of SCAD cases complicated by cardiogenic shock and the limited therapies available to treat these patients, these data are of clinical value in highlighting the feasibility of Impella use in SCAD. The Impella can be valuable for procedural support and in cardiogenic shock, especially in cases without evidence of ongoing ischemia.
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Affiliation(s)
- Shilpa Sharma
- Massachusetts General Hospital, Boston, Massachusetts
| | | | | | | | - Richard Sohn
- Providence Portland Medical Center, Portland, Oregon
| | - Adam Stys
- Sanford USD Medical Center, Sioux Falls, South Dakota
| | | | | | - Malissa Wood
- Massachusetts General Hospital, Boston, Massachusetts
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17
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Nakamura M, Imamura T, Ueno H, Kinugawa K. Current indication and practical management of percutaneous left ventricular assist device support therapy in Japan. J Cardiol 2019; 75:228-232. [PMID: 31870578 DOI: 10.1016/j.jjcc.2019.12.003] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2019] [Accepted: 12/02/2019] [Indexed: 11/17/2022]
Abstract
Impella (Abiomed, Danvers, MA, USA) is a recently-innovated (commercially available from 2017 in Japan) percutaneous left ventricular assist device which is inserted percutaneously and transfers blood from the left ventricle to the ascending aorta, improving systemic circulation and end-organ dysfunction as well as unloading left ventricle in patients with cardiogenic shock. Impella has not yet shown a significant survival benefit in patients with cardiogenic shock compared to intra-aortic balloon pump in randomized control trials, but gives powerful circulatory support immediately with minimally invasive manner when used in appropriate patients at optimal timing with adequate management. In this review article, we will introduce and discuss optimal and practical management of Impella therapy in Japan.
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Affiliation(s)
- Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
| | - Hiroshi Ueno
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Koichiro Kinugawa
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
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18
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Mohammedzein A, Taha A, Salwan A, Nambiar R. Impella Use in Cardiogenic Shock Due to Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction. JACC Case Rep 2019; 1:161-165. [PMID: 34316775 PMCID: PMC8301524 DOI: 10.1016/j.jaccas.2019.06.022] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/05/2019] [Accepted: 06/12/2019] [Indexed: 11/17/2022]
Abstract
Cardiogenic shock (CS) due to Takotsubo cardiomyopathy (TCM) is often managed with cautious fluid administration and inotropic support; however, the co-existence of a left ventricular outflow tract obstruction (LVOTO) can complicate this management approach. This report describes a case of CS due to TCM and LVOTO. It was successfully managed with the Impella 2.5. (Level of Difficulty: Intermediate.)
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Affiliation(s)
- Assad Mohammedzein
- Department of Internal Medicine, Texas Tech University Health Science Center, Amarillo, Texas
| | - Ahmed Taha
- Department of Internal Medicine, Texas Tech University Health Science Center, Amarillo, Texas
| | - Anu Salwan
- Department of Internal Medicine, Texas Tech University Health Science Center, Amarillo, Texas
| | - Rajesh Nambiar
- Department of Cardiology, Texas Tech University Health Science Center, Amarillo, Texas
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19
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Nakamura M, Nakagaito M, Hori M, Ueno H, Kinugawa K. A case of Takotsubo cardiomyopathy with cardiogenic shock after influenza infection successfully recovered by IMPELLA support. J Artif Organs 2019; 22:330-333. [DOI: 10.1007/s10047-019-01112-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 06/15/2019] [Indexed: 01/15/2023]
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