Transient left ventricular dysfunction (tako-tsubo phenomenon): Findings and potential pathophysiological mechanisms

Transient Left Ventricular Dysfunction from Cardiomyopathies to Myocardial Viability: When and Why Cardiac Function Recovers

Transient left ventricular dysfunction (TLVD), a temporary condition marked by reversible impairment of ventricular function, remains an underdiagnosed yet significant contributor to morbidity and mortality in clinical practice. Unlike the well-explored atherosclerotic disease of the epicardial coronary arteries, the diverse etiologies of TLVD require greater attention for proper diagnosis and management. The spectrum of disorders associated with TLVD includes stress-induced cardiomyopathy, central nervous system injuries, histaminergic syndromes, various inflammatory diseases, pregnancy-related conditions, and genetically determined syndromes. Furthermore, myocardial infarction with non-obstructive coronary arteries (MINOCA) origins such as coronary artery spasm, coronary thromboembolism, and spontaneous coronary artery dissection (SCAD) may also manifest as TLVD, eventually showing recovery. This review highlights the range of ischemic and non-ischemic clinical situations that lead to TLVD, gathering conditions like Tako-Tsubo Syndrome (TTS), Kounis syndrome (KS), Myocarditis, Peripartum Cardiomyopathy (PPCM), and Tachycardia-induced cardiomyopathy (TIC). Differentiation amongst these causes is crucial, as they involve distinct clinical, instrumental, and genetic predictors that bode different outcomes and recovery potential for left ventricular function. The purpose of this review is to improve everyday clinical approaches to treating these diseases by providing an extensive survey of conditions linked with TLVD and the elements impacting prognosis and outcomes.

Cardiac Arrest During Spinal Surgery: A Multidisciplinary Approach and Management of Takotsubo Syndrome

Cardiac arrest (CA) in the operating room is rare. Among known perioperative CA causes, Takotsubo syndrome (TTS) is a well-recognized one. Perioperative TTS is more common than existing reported cases therefore anesthesiologists should be aware of its diagnosis and management. TTS is an acquired and self-limited stress cardiomyopathy usually triggered by a precipitating stress factor and should be considered in any hospitalized patient presenting with symptoms such as acute coronary syndrome, cardiac arrhythmias or CA. A 67-year-old woman presented for lumbar discectomy in knee-chest position suffered CA two hours after the beginning of surgery. After a thorough examination, TTS was determined as the cause. This case report highlights the importance of TTS as a differential diagnosis of CA in the intraoperative setting as well as the usefulness of multimodal monitoring with cerebral monitoring to assist the prompt pulseless electric activity diagnosis. To our knowledge, this is the first case report in such circumstances.

Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 1-Pathophysiology and Diagnosis

First recognized in 1990, takotsubo syndrome (TTS) constitutes an acute cardiac condition that mimics acute myocardial infarction commonly in the absence of obstructive coronary artery disease; it is characterized by temporary left ventricular dysfunction, regularly in a circumferential apical, midventricular, or basal distribution. Considering its acute clinical presentation, coronary angiography with left ventriculography constitutes the gold standard diagnostic tool to exclude or confirm TTS. Frequently, TTS is related to severe emotional or physical stress and a subsequent increased adrenergic stimulation affecting cardiac function. Beyond clinical presentation, epidemiology, and novel diagnostic biomarkers, this review draws attention to potential pathophysiological mechanisms for the observed reversible myocardial dysfunction such as sympathetic overdrive-mediated multi-vessel epicardial spasms, microvascular dysfunction, the direct toxicity of catecholamines, lipotoxicity, and inflammation. Considering the long-term prognosis, further experimental and clinical research is indispensable to elucidate further pathophysiological mechanisms underlying TTS before randomized control trials with evidence-based therapeutic management can be performed.

[Acute coronary syndromes with ST elevation and angiographically normal culprit coronary arteries: Case report and update]

Acute coronary syndrome results in most cases of atherosclerotic plaque rupture. In a few cases, the physiopathological mechanism is different. This does not necessarily change the initial strategy but the subsequent treatments. We report three cases of clinical presentations of acute coronary syndrome whose pathophysiological mechanism is not or not mainly due to atherosclerotic lesions. Based on these cases and a review of the literature, two topics will be tackled: the diagnostic and therapeutic strategy in the management of Tako-tsubo cardiomyopathies and also acute coronary syndromes due to vasospastic angina.

Apical myocardial infarction with bizarre coronary images mimicking left ventricular apical ballooning syndrome: a case report

Introduction

Although several etiopathogenetic mechanisms have been proposed, the causes of left ventricular apical ballooning syndrome are still controversial.

Case presentation

A 51-year-old Japanese woman consulted the emergency room complaining of the sudden onset of anterior chest pain while shopping. We initially suspected her disease as left ventricular apical ballooning syndrome based on her clinical background and laboratory examinations. However, the initial coronary angiogram demonstrated diffuse lesions in her distal left anterior descending coronary artery, and she was finally diagnosed with apical myocardial infarction. The blood flow in her distal left anterior descending coronary artery had markedly improved in the chronic phase. If the reduced blood flow in her distal left anterior descending coronary artery was induced by coronary vasospasm and the vasospasm was relieved before the coronary angiogram was performed, this case must be diagnosed as left ventricular apical ballooning syndrome.

Conclusion

We think this case may promote discussion regarding the pathophysiology of left ventricular apical ballooning syndrome.

Amlodipine has a preventive effect on temporal left ventricular hypokinesia after emotional stress compared with an angiotensin II receptor blocker

PURPOSE

We previously reported that α- and β-blockers protected against emotional stress-induced cardiac dysfunction, but the protective effects of other antihypertensive drugs is unknown. The purpose of this study is to evaluate the ability of a calcium channel blocker, amlodipine, to prevent temporal left ventricular hypokinesia after emotional stress compared with an angiotensin II receptor blocker, olmesartan medoxomil.

METHODS

Rats premedicated with amlodipine (0.2 mg/kg), olmesartan (0.8 mg/kg), or vehicle were restrained for 30 min (immobilization stress: IMO) to reproduce emotional stress and then anesthetized to release stress. We measured the fractional area change (FAC) using echocardiography (SONOS5500) with a s12 probe (frequency 5-12 MHz, frame rate 120 Hz) and blood pressure and heart rate at the end of IMO and every 10 for 60 min after IMO.

RESULTS

During IMO, FAC in the amlodipine or the olmesartan group was as high as that in the vehicle group. At 20 min after IMO, FAC in the amlodipine group was significantly higher than in the other two groups (84 ± 8 vs. 60 ± 7 or 68 ± 15 %, p < 0.05). During IMO, blood pressure in the amlodipine or the olmesartan group was significantly lower than with vehicle (119 ± 6 and 110 ± 7 vs. 124 ± 5 mmHg, p < 0.05). After IMO, blood pressure in the olmesartan group was significantly lower than in the other two groups.

CONCLUSION

Acute administration of amlodipine could prevent a sudden drop in cardiac function after acute stress like IMO, but olmesartan did not. Amlodipine might have a protective effect on temporal left ventricular hypokinesia after emotional stress, which might not be related to decreased blood pressure.

Cardioembolic outcomes in stress-related cardiomyopathy complicated by ventricular thrombus: a systematic review of 26 clinical studies

BACKGROUND

The stress-related cardiomyopathy (SRC) is a relatively novel cardiac syndrome characterized by peculiar transient left ventricular dysfunction, which accounts for approximately 1-3% of patients with symptoms that initially appear to be an acute coronary syndrome. To date, the true incidence and clinical significance of left ventricular thrombus and related embolic outcomes in these patients have not been fully established.

METHODS

The present systematic review aimed to report updated case series of SRC patients with left ventricular thrombus and/or cardioembolic events complicating the course of syndrome, in an attempt to summarize their demographic and clinical characteristics.

RESULTS

Overall, 33 eligible studies (44 patients) were selected through the PubMed-Medline archives (December 2002-April 2009), but only 26 (36 patients) matched our inclusion criteria. Left ventricular thrombus was detected in 32 patients (89%), whereas thromboembolic events occurred in 12 (33%). Morphological characteristics of thrombi are described through the article. Women >65 years of age presenting with deep/giant negative T-waves on admission ECG seem more likely to have thrombus-related embolic complications.

CONCLUSIONS

Important findings from this updated review indicate that LVT approximately occurs in 5% of the estimated worldwide SRC population, similar to historical incidence in patients with myocardial infarction. In a third of cases (approximately 1.6% of above guesstimate) nonfatal cardioembolic outcomes (brain ischemia in 75% of cases) have been documented. It is worthy considering early anticoagulant therapy, especially in patients at a higher risk of thromboembolic disease, irrespective of the presence of LVT at admission.

Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: a systematic review

BACKGROUND

Though a severe left ventricular systolic dysfunction has been described in most patients with Takotsubo-like (or Apical Ballooning) syndrome, the occurrence of intra-cavitary thrombus formation seems to be such an exceptional finding. However, no large studies but single case descriptions of this complication are available over the last decade in the literature.

METHODS

By searching for the PubMed-Medline database we selected 14 studies that met our eligibility criteria.

RESULTS

Demographic, clinical and morphofunctional characteristics of 15 patients who where described to have left ventricular thrombosis as a complication of the Takotsubo-like syndrome are comprehensively described in this review. Cardioembolic complications (stroke in 3 cases, renal infarction or popliteal artery thrombosis in other two) occurred in 33.3% out of them. The incidence of thrombus formation and related systemic embolisms in the general population with this syndrome were established on the basis of such available historical data and reviews on this subject.

CONCLUSION

Left ventricular thrombus formation has been reported in at least 14 studies (15 patients) over the last decade until the end of 2007. This approximately results in about 2.5% of all the patients with documented Takotsubo-like syndrome. Cardioembolic complications occurred in 5/15 cases, corresponding to 0.8% of the whole known population.

Prolonged and fluctuating giant T-wave inversion after electroconvulsive therapy

A 76-year-old woman was scheduled to receive 8 treatments of electroconvulsive therapy (ECT) for severe depression. Although she experienced no adverse consequences in the first 2 treatments, giant T-wave inversion ensued from the third treatment despite no change in anesthesia or technical parameters of ECT. T-wave inversion appeared to have almost disappeared 8 days after the third ECT, but reappeared at 3 weeks after treatment during severe pain from gallbladder stone. T-wave inversion lasted for 4 months with gradual attenuation. Exaggerated sympathetic stimulation associated with ECT as physical and emotional stressors might have played a role in the appearance of T-wave inversion similar to catecholamine-induced cardiomyopathy. Furthermore, reappearance of T-wave inversion may have been involved in additive effects of pain from gallbladder stone on vulnerability due to a catecholamine-induced cardiomyopathy-like condition.