Stress-Induced Cardiomyopathy (Takotsubo Cardiomyopathy) After Liver Transplantation—Report of Two Cases

Takotsubo cardiomyopathy after solid organ transplantation: a scoping review

Takotsubo syndrome (TTS) is a stress-induced cardiomyopathy that causes temporary left ventricular wall motion abnormalities and abrupt reversible heart failure. The incidence of perioperative TTS is proportional to the severity of surgical trauma, the duration of the procedure, and the degree of apparent sympathetic activity. A growing number of articles have discussed TTS after a solid organ transplant (SOT), which is one of the circumstances in which physical and emotional stress are at their highest levels. The majority of published cases involved patients who had received an orthotopic liver transplant (OLT). TTS occurred in 0.3-1.7% of liver transplant recipients, but a limited number of cases of TTS in patients who had received kidney, heart, or lung transplants have also been documented. In this study, we analyzed the TTS instances that developed after SOT, highlighting the symptoms and causes as well as the various treatment approaches that were applied. Most TTS cases following OLT and kidney transplant cases occurred in the first week of the surgery. However, the majority of cases occurred years after heart transplantation. Dizziness, dyspnoea, and chest discomfort are the most typical symptoms. Patients may also experience syncope and generalized weakness. In spite of this, the symptoms differ depending on the transplanted organ. Dyspnoea is a common symptom after lung transplants, whereas chest discomfort and dizziness are a common symptom after liver and kidney transplants. Yet, chest pain is not a typical symptom after a heart transplant.

Takotsubo Cardiomyopathy and Autoimmune Disorders: A Systematic Scoping Review of Published Cases

Introduction

Takotsubo cardiomyopathy (TCM) features transient left ventricular apical dysfunction or ballooning. The underlying mechanism remains elusive; however, evidence suggests the role of different physical and psychological stressors. We systematically reviewed patients presenting with TCM and autoimmunity to explore the link between the two conditions.

Methods

We applied the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) to report this review. Using keywords related to autoimmune/immune-mediated diseases and TCM, we searched PubMed, Scopus, and WOS in March 2022. The final results were added to a data extraction sheet. Data were analyzed by SPSS version 26.0.

Results

Our search yielded 121 studies, including 155 patients. Females were considerably predominant. Most patients had a history of autoimmune disease, and almost a third had a history of cardiovascular disease. Dyspnea and chest pain were the most common chief complaints. More than 70% of patients had experienced physical stress. Myasthenia gravis, systemic lupus erythematosus, and multiple sclerosis were the most frequently reported autoimmune diseases.

Conclusion

There were similarities in age and sex compared to classic TCM. TCM should be considered as a differential diagnosis for ACS, especially in patients with a positive background of autoimmunity. A precise reporting system is required for further studies.

Case of takotsubo cardiomyopathy after surgical treatment of liver hydatid cyst: A case report

BACKGROUND

Takotsubo cardiomyopathy, also called apical ballooning syndrome, is a disease that is often triggered by stress factors in postmenopausal women and mimics acute coronary syndrome. The aim of this article is to draw attention to takotsubo cardiomyopathy after surgical treatment of liver hydatid cyst.

CASE SUMMARY

A 50-year-old diabetic and hypertensive female patient was evaluated preoperatively before general surgery for liver hydatid cyst, and no cardiac problems were found. The patient was discharged on the 3rd postoperative day without any postoperative complications. On postoperative day 5, the patient presented to the emergency department with fever, shortness of breath, chills, and shivering and was hospitalized with the diagnosis of pneumonia. The troponin levels remained high during follow-up. Echocardiography was performed on postoperative day 7, after which the patient was referred to a tertiary center with the diagnosis of non-ST-elevation myocardial infarction due to akinesia in the apical region. Coronary angiography performed at the tertiary center showed normal coronary anatomy, and the patient was diagnosed with takotsubo cardiomyopathy.

CONCLUSION

Takotsubo cardiomyopathy mimicking myocardial infarction without ST segment elevation may develop after surgical treatment of liver hydatid cyst.

Meta-Analysis and Clinical Features of Perioperative Takotsubo Cardiomyopathy in Noncardiac Surgery

Perioperative takotsubo cardiomyopathy (pTCM) is an increasing condition defined as cardiomyopathy in the setting of emotional and physiologic stressors imposed by surgery. We aimed to classify and understand the presentation, management, and prognosis of noncardiac surgery pTCM in published cases. As such, a review of previous studies using the PubMed, Embase, Cochrane, and Web of Science databases was conducted to obtain case reports and series reporting noncardiac pTCM from inception to September 2022, and a crude analysis was conducted to classify the clinical features. Of the 1,002 studies, 96 met our inclusion criteria, of which 101 cases were extracted and included in the final systematic review. A total of 29.7% of cases occurred during general surgery and 20.8% during transplant procedures. The median age at presentation was 55 years, with a 42 to 65 interquartile range. The prevalence of hypertension and mood disorders were 22.8% and 9.9%, respectively. Before the procedures, physiologic stressors occurred more commonly than emotional stressors (20.8% and 11%, respectively). Objective findings, including ST-T-wave changes, new arrhythmias, and hypotension, were the most common initial presenting symptoms. Most cases occurred during emergence from surgery or on the first postoperative day. Mechanical circulatory support was required in 15.8% of the cases, and the all-cause in-hospital mortality was 6.9%. The ejection fraction and symptoms improved within a median of 2 weeks after diagnosis (interquartile range 1 to 6). In conclusion, the risk factors, triggers, and outcomes of pTCM appear to differ from those of classic nonperioperative TCM presentations. Future studies will help shed light on this more frequently diagnosed condition complicating some noncardiac surgical cases.

Incidence, predictors and outcomes of new onset systolic heart failure following Orthotopic liver transplant: A systematic review

BACKGROUND

New onset Systolic heart failure (SHF), characterized by new onset left ventricular (LV) systolic dysfunction with a reduction in ejection fraction (EF) of <40%, is a common cause of morbidity and mortality among Orthotopic liver transplant (OLT) recipients. Therefore, we aimed to evaluate the prevalence, the pre-transplant predictors, and the prognostic impact of SHF post-OLT.

METHODS

We conducted a systematic review of the literature using electronic databases MEDLINE, Web of Science, and Embase for studies reporting acute systolic heart failure post-liver transplant from inception to August 2021.

RESULT

Of 2604 studies, 13 met the inclusion criteria and were included in the final systematic review. The incidence of new-onset SHF post OLT ranged from 1.2% to 14%. Race, sex, or body mass index did not significantly impact the post-OLT SHF incidence. Alcoholic liver cirrhosis, pre-transplant systolic or diastolic dysfunction, troponin, brain natriuretic peptide (BNP), blood urea nitrogen (BUN) elevation, and hyponatremia were noted to be significantly associated with the development of SHF post-OLT. The significance of MELD score in the development of post-OLT SHF is controversial. Pre-transplant beta-blocker and post-transplant tacrolimus use were associated with a lower risk of developing SHF. The average 1-year mortality rate in patients with SHF post-OLT ranged from 0.00% to 35.2%.

CONCLUSION

Despite low incidence, SHF post-OLT can lead to higher mortality. Further studies are required to fully understand the underlying mechanism and risk factors.

Takotsubo Syndrome in Orthotopic Liver Transplant: A Systematic Review and Pooled Analysis of Published Studies and Case Reports

BACKGROUND

Takotsubo syndrome (TTS) has been reported in solid-organ transplant recipients. However, the pooled data regarding TTS after liver transplant remain limited.

METHODS

A systematic review was performed through February 2022 using PubMed, Embase, Scopus, and Google Scholar to review case reports/series and original studies on liver transplant-associated TTS. Descriptive analysis was performed for case reports and pooled analysis for the prevalence using random effects models.

RESULTS

A total of 56 case reports were included from 30 articles (51.8 % male; mean age, 53 years; India 56%, US 27%, and Europe 8.93%) and 10 original studies (US 88.65%, India 10.92%) revealing liver transplant-associated TTS. The pooled prevalence of TTS was 1.1% (95% Cl, 0.6%-1.7%) of all liver transplants with comparable rates in studies from India and the US (P = .92). Indications for liver transplant included end-stage liver disease due to alcohol-related cirrhosis (25%), hepatitis C virus infection (17.9%), hepatocellular carcinoma (10.7%), and non-alcohol-related steatohepatitis (8.9%); the average Model for End-Stage Liver Disease score was 24.75. TTS commonly presented as hypotension (30%), dyspnea (14%), and oliguria, occurring mostly post-transplant (82%), whereas 14% were intraoperative. Common electrocardiogram findings were ST changes, ventricular tachycardia, and atrial fibrillation. Common echocardiogram findings showed left ventricular apical ballooning in 46.5% of cases and reduced ejection fraction < 20% in 41.9% of cases. Common complications were cardiogenic shock (32.1 %), acute kidney injury (12.5%), arrhythmia, stroke, cardiac arrest, and hepatic artery thrombosis. Mechanical circulatory support was required in 30.3%. Recurrence was reported in 15, and mortality in 30.4% of patients.

CONCLUSIONS

Takotsubo syndrome prevalence after liver transplant is significantly higher than TTS prevalence in general US hospitalizations with potentially worse outcomes. Prospective registries reporting TTS in liver transplant recipients are warranted.

Takotsubo cardiomyopathy following liver transplantation and COVID-19 infection

Takotsubo cardiomyopathy involves transient systolic dysfunction of the left ventricle thought to be caused by a physiologic stress response and associated catecholamine release. We present a previously undocumented cause of this stress response involving a 53-year-old man with hepatocellular carcinoma and alcohol-associated cirrhosis who initially presented for liver transplantation. Shortly after successful transplantation, the patient developed a COVID-19 infection and takotsubo cardiomyopathy.

New onset nonischemic cardiomyopathy post liver transplantation

A new onset acute heart failure (HF) with a sudden drop in the left ventricular ejection fraction (LVEF) post orthotopic liver transplant (LT) is a rare but a potentially fatal complication. Because in most of the cases there is no evidence of coronary thrombosis, it can be classified as nonischemic cardiomyopathy. More specifically, clinical presentation of this syndrome shares many features with stress-induced or takotsubo cardiomyopathy. The known factors that predispose these patients to acute HF during or shortly after LT include cirrhotic cardiomyopathy, rapid hemodynamic changes during LT surgery, and the large concentrations of catecholamines, either administered or released endogenously during surgery. The hemodynamic changes during surgery, such as the drop in preload during the anhepatic phase (occasionally requiring massive transfusions and vasopressors) and subsequent increase in preload with acidic and hyperkalemic plasma in the reperfusion phase, lead to rapid electrolyte and hemodynamic shifts. In several cases, intraoperative onset of HF, with or without ventricular arrythmia, could be timed to the reperfusion phase (and occasionally in the anhepatic and pre-anhepatic phases). In other cases, the HF syndrome started hours to days post-surgery. Recovery of cardiac function occurred in the majority of patients during the same admission; however, these patients generally need significantly longer hospitalizations and aggressive supportive care (occasionally requiring mechanical ionotropic and ventilatory support). If recover, the patients have a similar 1-year mortality as those LT patients that did not have this complication. Because no reliable risk stratification currently exists, intraoperative transesophageal echocardiography might be the most dependable way of detecting and addressing this syndrome promptly. Given the mechanism of takotsubo cardiomyopathy, beta-blockade and a preferential use of non-catecholaminergic vasopressors may be a reasonable way to manage this syndrome.

Hepatic Artery Thrombosis and Takotsubo Syndrome After Liver Transplantation - Which Came First?

BACKGROUND Takotsubo syndrome is a transient, reversible, stress-induced cardiomyopathy that affects only 1.4% of liver transplant patients and can cause complications, including cardiogenic shock, arrhythmia, and thromboembolism. Hepatic artery thrombosis is also rare, affecting just 2-4% of these patients, but can have disastrous consequences. Here, we describe a case of concurrent takotsubo syndrome and hepatic artery thrombosis in a postoperative liver transplant recipient. CASE REPORT The patient was a 66-year-old man who underwent living donor liver transplantation for non-alcoholic steatohepatitis. On postoperative day 3, he became lethargic and tachycardic to the 120 s. Work-up, including EKG, troponin I, BNP, and transthoracic echocardiogram, was characteristic for takotsubo syndrome. His LVEF of 15-20% was markedly reduced compared to his baseline of 50-55% from 6 months prior. Hepatic ultrasonography showed no hepatic arterial flow, prompting emergent return to the OR, where intraoperative evaluation revealed hepatic artery thrombosis. The graft was salvaged after hepatic artery thrombectomy and arterial anastomosis revision. We are unable to determine which event caused the other in this case, as both takotsubo syndrome and hepatic artery thrombosis manifested within the same time frame. CONCLUSIONS It is important to recognize takotsubo syndrome as a potential cause of cardiac dysfunction and hepatic artery thrombosis in liver transplant patients, and also be aware that hepatic artery thrombosis can precipitate takotsubo syndrome.

Acute Cardiac Failure Due to Takotsubo Cardiomyopathy Secondary to a Phone Call for Lung Transplantation: A Case Report

Lung transplantation is a therapeutic option for certain end-stage lung diseases. The phone call for lung transplantation is a major event in the life of these patients; as a result, it can generate significant stress. We herein present the case of a 58-year-old female patient with end-stage chronic obstructive pulmonary disease (COPD) who, while on the lung transplantation waiting list, received such a call. Complete transplant work-up, including cardiac tests undertaken shortly before, had revealed no contraindication to lung transplantation. She was admitted with severe acute respiratory failure, and her extensive work-up was compatible with pulmonary edema due to takotsubo cardiomyopathy. The lung transplantation was thus cancelled, owing to the patient's health condition and the poor quality of the graft as well. The patient stayed in the intensive care unit for several days, requiring noninvasive ventilation. The left ventricular function recovered completely within 10 days postdiagnosis, and the patient was discharged 13 days after her admission. The patient was transplanted 1 month thereafter, without any particular problems; she is currently, 8 months post-transplantation, in good condition. In the given case, the call for lung transplantation could have generated emotional stress severe enough to lead to takotsubo cardiomyopathy.

Severe takotsubo cardiomyopathy following orthotopic liver transplantation: A case series

INTRODUCTION

Acute decompensated heart failure is a known complication following orthotopic liver transplant. Among those, there are some cases of takostubo type cardiomyopathy (TC), commonly referred to as "broken heart syndrome". While the exact mechanism of TC is unknown, it frequently proceeds a physical or emotional stressor. Here we present a series of seven cases of TC following orthotopic liver transplant.

METHODS

A retrospective chart review was conducted on 454 patients were identified as having post-operative cardiac dysfunction in the setting of orthotopic liver transplantation. Of those, seven were identified as having TC based on apical ballooning, acute heart failure without evidence of coronary artery disease. All seven underwent pre-operative cardiac evaluation per protocol. Extensive chart review was performed on the seven patients to identify pre and post-operative qualities.

RESULTS

At this single institution, TC affected 7/454 patients, reflecting an incidence of 1.5% over the eight year study period. Of the seven patients affected, one expired. Patients represented a mix of emergent and scheduled transplantation in the setting of end stage liver disease (ESLD). Patients had a mix of etiologies related to their ELSD including hepatitis C, alcoholic cirrhosis, and non-alcoholic steatohepatitis.

DISCUSSION

It is important to recognize TC as a potential complication following liver transplantation so as to detect cases earlier in the disease course and begin early goal-directed care.

A rare case of transient left ventricular apical ballooning syndrome following living donor liver transplantation: A case report and literature review

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Transient Left Ventricular Apical Balloon Syndrome (LV-ABS) is an acute dysfunction of the left ventricle.

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Its clinical feature is similar to myocardial infarction.

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The echocardiogram show characteristic finding which is different from that of myocardial infarction.

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LV-ABS is rare, however, should be considered after liver transplantation.

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Proper diagnosis is important to restore cardiac function although it improve almost normally with conservative treatment.

Introduction

Transient Left Ventricular Apical Balloon Syndrome (LV-ABS) is an unknown acute dysfunction of the left ventricle, which develops under emotional or physical stress events like the major surgical postoperative period.

Presentation of case

A 68-year-old woman diagnosed with hepatitis C cirrhosis was admitted for living donor liver transplantation (LDLT). No evidence for underlying cardiac or pulmonary disease was found. LDLT was performed, and her intra and post-operative course was uneventful. On post-operative day 4, dyspnea and tachycardia were observed. Echocardiography showed a severe wall motion abnormality with ballooning of the apex with normal basilar wall motion and a severely impaired left ventricular function with an ejection fraction (EF) of 40%. Blood tests showed greatly increased level of N-terminal pro-brain natriuretic peptide (NT- pro BNP). Evidence of significant ischemic heart disease was not obtained and a transient LV-ABS was diagnosed. Although she required intensive care, her cardiac function became normal by conservative treatment.

Discussion

Transient LV-ABS has been reported to occur more frequently in post-menopausal women with reduced estrogens reported to protect myocardium from sympathetic stress after mental or physical stress events. It has been suggested that this disease arises from myocardial stunning with high levels of circulating catecholamines and stress related neuropeptides. However, even in a serious condition, cardiac function has recovered normally in all cases by appropriate care.

Conclusion

Transient LV-ABS is one cause of cardiac dysfunction after LDLT, and it is important to strictly manage cardiac function when diagnosed as transient LV-ABS.

An uncommon cause for grade 3 primary graft dysfunction after lung transplantation: Takotsubo cardiomyopathy

Takotusubo cardiomyopathy is an acute, temporary cardiac syndrome which is important for the differential diagnosis of dynamic electrocardiography alterations. Takotsubo cardiomyopathy related to lung transplantation is rather rare in the literature with only two case reports. Our case is the first Takotsubo cardiomyopathy case that manifested in the early period after lung transplantation. In this article, we present a 61-yearold male patient who was performed bilateral sequential lung transplantation for chronic obstructive pulmonary disease. During follow-up, Takotsubo cardiomyopathy was diagnosed, primary graft dysfunction related to cardiomyopathy was observed, and extracorporeal membrane oxygenation was required.

Takotsubo Cardiomyopathy Resulting in Cardiac Arrest in a Patient Undergoing Liver Transplantation

Cardiac complications during and after liver transplantation are a common cause of death. Although considered to be uncommon, takotsubo cardiomyopathy, which is characterized by reversible left ventricular akinesis without coronary artery obstruction, is becoming increasingly reported. Herein we have presented a case of reversible stress-induced takotsubo cardiomyopathy resulting in cardiac arrest in a patient undergoing liver transplantation.

Use of extracorporeal membrane oxygenation for treating acute cardiomyopathy after liver transplantation: a case report

We report the case of a female patient, 58 years of age, without known heart disease, who underwent liver transplantation without complications. On the second postoperative day, the patient developed cardiogenic shock secondary to stress-induced cardiomyopathy (Takotsubo-like syndrome). The patient was successfully managed with veno-arterial peripheral extracorporeal membrane oxygenation for 6 days, with complete recovery of cardiac function and of the hepatic graft. Coronary syndrome and acute myocarditis were excluded as the causes of the shock. The use of extracorporeal membrane oxygenation in this scenario is possible and safe, considering its specialized protocols and treatment.

Mending a Broken Heart: Treatment of Stress-Induced Heart Failure after Solid Organ Transplantation

Stress-induced heart failure, also known as Broken Heart Syndrome or Takotsubo Syndrome, is a phenomenon characterized as rare but well described in the literature, with increasing incidence. While more commonly associated with postmenopausal women with psychiatric disorders, this entity is found in the postoperative patient. The nonischemic cardiogenic shock manifests as biventricular failure with significant decreases in ejection fraction and cardiac function. In a review of over 3000 kidney and liver transplantations over the course of 17 years within two transplant centers, we describe a series of 7 patients with Takotsubo Syndrome after solid organ transplantation. Furthermore, we describe a novel approach of successfully treating the transient, though potentially fatal, cardiogenic shock with a percutaneous ventricular assistance device in two liver transplant patients, while treating one kidney transplant patient medically and the remaining four liver transplant patients with an intra-aortic balloon pump. We describe our experience with Takotsubo's Syndrome and compare the three modalities of treatment and cardiac augmentation. Our series is novel in introducing the percutaneous ventricular assist device as a more minimally invasive intervention in treating nonischemic heart failure in the solid organ transplant patient, while serving as a comprehensive overview of treatment modalities for stress-induced heart failure.

Perioperative Takotsubo Cardiomyopathy: A Systematic Review of Published Cases

Takotsubo cardiomyopathy (TCM) is a condition that is characterized as a transient ventricular dysfunction in the absence of obstructive coronary artery disease (CAD) and is usually triggered by an acute medical illness or intense physical or emotional stress. Multiple cases of perioperative TCM (pTCM) have been reported from around the world, but a qualitative analysis of these cases has not yet been done. For this systematic review, we searched PubMed for case reports and case series of pTCM published from 1966 to April 2015 with the objective being to evaluate whether differences in demographics, clinical features and outcomes exist between pTCM and nonperioperative (npTCM), as well as to attempt to identify any predictors of the severe form of pTCM, which requires mechanical circulatory support (MCS) devices or leads to death. A total of 93 articles describing 102 cases were retrieved and reviewed. The findings were compared with the analysis of the International Takotsubo Registry by Templin et al and a systematic review of mainly non-perioperative TCM (npTCM) by Gianni et al. Although we were unable to identify definitive risk factors for pTCM, our review suggests that pTCM appears to occur in younger patients and with a lower likelihood of ST segment elevations and T-wave abnormalities than in npTCM. No demographic or clinical factors were identified that were predictive of more severe outcomes. As TCM in general can be a life-threatening event, it would therefore be prudent to consider pTCM within a differential diagnosis in any patient who decompensates in the perioperative period.

A New Insight Into Sudden Cardiac Death in Young People: A Systematic Review of Cases of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC) causes sudden cardiac death and has garnered increased attention worldwide in recent years. However, few studies have clearly classified the risk factors for this disease, including gender, race and morbidity, as well as the physical and mental stressors that can exacerbate the disease, particularly in young patients. To better analyze the characteristics of young TTC patients, we performed a systematic review of reported cases involving young patients.A computer-assisted search was performed using prominent electronic medical information sources to identify literature published between January 1965 and December 2013. Relevant studies containing clinical data of young TTC patients were included.Ninety-six records that included information about 104 cases were ultimately selected for our review. Several of the following results were noted: First, physical stress was more likely to exacerbate TTC than was mental stress in young patients. Second, more female than male TTC patients were noted among both young patients and the general population. Third, ethnicity appears to play no role in the disease, as no significant differences were noted among individuals of different races with respect to clinical characteristics, morbidity or stressors. Fourth, the clinical manifestations of TTC were similar to those of other cardiac diseases, including coronary heart disease. However, TTC may be detected using the combination of echocardiography and ventriculography.Clinicians should consider TTC if young patients present with symptoms similar to those of coronary heart disease so that harmful treatments such as coronary artery stent placement may be avoided. Moreover, the answers to questions regarding the clinical diagnostic criteria, etiology, pathophysiology, and the management of this syndrome in youth remain unclear; therefore, further research is needed.

Natural history of cardiac arrest in patients with takotsubo cardiomyopathy

Cardiac arrest (CA) is relatively rare but lethal complication of takotsubo cardiomyopathy (TTC). In most instances, patients are diagnosed with TTC after CA, making it difficult to distinguish if TTC is the precipitant or the consequence of the index event. In this systematic review, patient-level data were obtained to seek out the characteristics of patients in whom the underlying cause of CA is TTC. A comprehensive search of 4 major databases (Embase, Ovid MEDLINE, PubMed, and Google Scholar) was performed from their inception to the last week of September 2014. Of 186 citations, 62 case studies were included in the analysis, providing patient-level data on 77 patients. In 60 patients (78%), the diagnosis of TTC was made after CA. Patients presenting with CA were younger (mean age 49.5 ± 16 vs 64.9 ± 11 years, p <0.0001) and had relatively shorter corrected QT interval (mean 530 ± 101 vs 616 ± 140 ms) on electrocardiography. TTC-related hypotension was the major cause of CA in the acute phase, while a long corrected QT interval triggered CA in the subacute (24- to 72-hour) phase. In 11 patients, CA was not directly instigated by TTC despite a left ventricular appearance matching TTC. In conclusion, in TTC, CA typically develops within the first 3 days of presentation and is the result of long corrected QT interval-induced polymorphic ventricular tachycardia. Secondary TTC, in which patients present with typical left ventricular features after CA, likely represents a distinct cohort in which identifiable inheritable arrhythmias or structural heart disease should be sought.

Stress-induced cardiomyopathy

OBJECTIVES

Reversible stress-induced cardiac dysfunction is frequently seen as a complication of a multitude of acute stress states, in particular neurologic injuries. This dysfunction may be difficult to distinguish between that caused by myocardial ischemia and may impact both the treatment strategies and prognosis of the underlying condition. Critical care practitioners should have an understanding of the epidemiology, pathophysiology, clinical characteristics, precipitating conditions, differential diagnosis, and proposed treatments for stress-induced cardiomyopathy.

DATA SOURCES

MEDLINE database search conducted from inception to August 2014, including the search terms "tako-tsubo," "stress-induced cardiomyopathy," "neurogenic cardiomyopathy," "neurogenic stress cardiomyopathy," and "transient left ventricular apical ballooning syndrome". In addition, references from pertinent articles were used for a secondary search.

STUDY SELECTION AND DATA EXTRACTION

After review of peer-reviewed original scientific articles, guidelines, and reviews resulting from the literature search described above, we made final selections for included references and data based on relevance and author consensus.

DATA SYNTHESIS

Stress-induced cardiomyopathy occurs most commonly in postmenopausal women. It can be precipitated by emotional stress, neurologic injury, and numerous other stress states. Patients may present with symptoms indistinguishable from acute coronary syndrome or with electrocardiogram changes and wall motion abnormalities on echocardiogram following neurologic injury. Nearly all patients will have an elevated cardiac troponin. The underlying etiology is likely related to release of catecholamines, both locally in the myocardium and in the circulation. Differential diagnosis includes myocardial infarction, myocarditis, neurogenic pulmonary edema, and nonischemic cardiomyopathy. Although the natural course of stress-induced cardiomyopathy is resolution, treatment strategies include sympathetic blockade and supportive care.

CONCLUSIONS

Stress-induced cardiomyopathy may mimic myocardial infarction and is an important condition to recognize in patients with underlying stress states, particularly neurologic injuries.

Recent advances in the diagnosis and management of cirrhosis-associated cardiomyopathy in liver transplant candidates: advanced echo imaging, cardiac biomarkers, and advanced heart failure therapies

Patients with end-stage liver disease in need of liver transplantation increasingly are older with a greater burden of cardiac disease and other co-morbidities, which may increase perioperative risk and adversely affect long-term prognosis. Cirrhosis of any etiology manifests hemodynamically as a state of low systemic vascular resistance, with high peripheral, but low central blood volume, leading to a state of neurohormonal activation and high cardiac output, which may adversely affect cardiac reserve under extreme perioperative stress, aptly termed cirrhosis-associated or cirrhotic cardiomyopathy. Evidence of asymptomatic cirrhotic cardiomyopathy may be found in subtle electrocardiographic and echocardiographic changes, but may progress to severe heart failure under the demands of bleeding and transfusions, vasopressors, rebounding peripheral vascular resistance, withdrawal of cardioprotective beta-blockers and mineralocorticoid antagonists, exacerbated by sepsis or systemic inflammatory response syndrome. This review will add to the current body of literature on cirrhotic cardiomyopathy by focusing on the role of advanced echocardiographic imaging techniques, cardiac biomarkers, and advanced heart failure therapies available to manage patients with cirrhotic cardiomyopathy while waiting for liver transplant and during the perioperative period.

Reversible non-ischaemic cardiomyopathy and left ventricular dysfunction after liver transplantation: a single-centre experience

BACKGROUND & AIMS

Non-ischaemic cardiomyopathy (NIC) is an early complication of liver transplantation (LT). Our aims were to define the prevalence, associated clinical factors, and prognosis of this condition.

METHODS

A retrospective study was performed on patients undergoing LT at our institution from January 2005 to December 2012. Patients who developed NIC were identified. Data collected included demographic and clinical data.

RESULTS

A total 1460 transplants were performed in this period and seventeen patients developed NIC. Pretransplant median QTc interval was 459 (range, 405-530), and median E/A ratio was 1 (range, 0.71-1.67). Fourteen patients (82%) were severely malnourished and required nutritional support. Thirteen patients (76%) had renal insufficiency. Median time to onset was 2 days post-transplant (range, 0-20). Echocardiograms showed global left ventricular hypokinesis and a decrease in ejection fraction (EF) from a median of 65% (range, 50-81) pretransplant to a median of 21% (range, 15-32). Median raw model for end-stage liver disease (MELD) score was 29 in patients with NIC vs. 18 in patients without cardiomyopathy (P = 0.01). There was no significant difference between recipients with NIC vs. recipients without cardiomyopathy regarding donor age, donor risk index, and cold and warm ischaemia time. Recovery of cardiac function occurred in 16 patients, with a median EF of 44% (range, 25-65%) at the time of discharge. The last echocardiogram available showed a median EF of 59% (range, 49-73%). One-year survival of NIC patients was 94.1%.

CONCLUSION

Non-ischaemic cardiomyopathy is a rare complication after LT. Patients with NIC are critically ill, with high MELD score, and severe malnutrition.

Loss of speech after living-related donor liver transplantation: detection of the lesion by diffusion tensor image

INTRODUCTION

Loss of speech after living-related liver transplantation is uncommon. Either immunosuppressive agents, related sequelae, or a neurological event may cause it.

CASE REPORT

A 46-year-old man developed dysarthria and dysphagia on the 10th day after living-related donor liver transplantation for alcoholic cirrhosis with Child-Pugh class C. Brain magnetic resonance images and electroencephalograms could not detect any lesion, but the diffusion tensor image showed a subacute lacunar infarction at right midbrain. The patient's speech improved 1 month after rehabilitation.

CONCLUSIONS

Some unexpected neurological events, such as loss of speech, may occur after liver transplantation. The differential diagnosis becomes very important before active treatment. Magnetic resonance imaging supplemented with diffusion tensor imaging is an effective imaging study in establishing the diagnosis.

Postoperative left ventricular apical ballooning: Transient Takotsubo cardiomyopathy following orthotopic liver transplantation

PATIENT

Female, 51 FINAL DIAGNOSIS: Takotsubo cardiomyopathy Symptoms: -

MEDICATION

- Clinical Procedure: - Specialty: Cardiology • Transplantology.

OBJECTIVE

Rare disease.

BACKGROUND

Left ventricular apical ballooning syndrome (LVAB), also known as Takotsubo cardiomyopathy, is a cardiac syndrome characterized by transient left ventricular dysfunction in the absence of obstructive atherosclerotic coronary artery disease. An episode of emotional stress, typically in female patients, is believed to precede and trigger the development of this syndrome.

CASE REPORT

We report a case of Takotsubo cardiomyopathy that developed after orthotopic liver transplantation in a 51-year-old woman. On D2 (day 2) the patient had severe hemodynamic compromise. Echocardiography showed systolic dysfunction of the left ventricle (LV), with ejection fraction (EF) of 20% and anteroapical akinesis and ballooning of the apical 2/3 of the LV. Troponin T was elevated but other markers of myocardial necrosis were negative, as was coronary angiography. From D7 onward, there was an improvement in the hemodynamics in conjunction with a gradual increase of LV EF. The patient was dismissed from the hospital on D30 with signs of normal cardiac function and LV motion and EF of 50%. Liver function was also excellent.

CONCLUSIONS

Every major operation, including liver transplantation, is associated with emotional stress for the patient. Therefore, it is necessary to consider Takotsubo cardiomyopathy in the differential diagnosis of heart failure developing early after LT, and clinicians should subsequently use adequate diagnostic and therapeutic measures.

Ventricular Fibrillation in a Patient with Tachycardia-Induced Cardiomyopathy after Liver Transplantation

We report a case of atrial fibrillation-related tachycardia induced cardiomyopathy and ventricular fibrillation after liver transplantation in a 41-year-old man with end-stage liver failure. Atrial fibrillation and congestive heart failure occurred postoperatively. Cardiac arrests due to ventricular fibrillation occurred 6 months after the operation with subsequent implantations of an implantable cardioverter-defibrillator. Ventricular arrhythmias did not recur during the 18 months after normalization of heart functions with guideline-directed medical treatments.