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Madias JE. Left ventricular outflow tract obstruction/hypertrophic cardiomyopathy/takotsubo syndrome: A new hypothesis of takotsubo syndrome pathophysiology. Curr Probl Cardiol 2024; 49:102668. [PMID: 38797507 DOI: 10.1016/j.cpcardiol.2024.102668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 05/29/2024]
Abstract
The pathophysiology of TTS is still elusive. This viewpoint proposes that TTS is an acute coronary syndrome, engendered by an ASNS/catecholamine-induced LVOTO, which results in an enhanced wall stress and afterload-based supply/demand mismatch, culminating in a segmental myocardial ischemic injury state, in susceptible individuals. Such individuals are felt to be particularly women with chronic hypertension, known or latent HCM, or non-HCM segmental myocardial hypertrophy, and certain structural abnormalities involving the LV and the MV apparatus. Recommendations are provided to explore further this hypothesis, while maintaining our focus on all other advanced TTS pathophysiology hypotheses for all patients, or those who do not experience LVOTO, men, the young, and patients with reverse, mid-ventricular, or right ventricular TTS, in whom more prolonged hyperadrenergic stimulation and/or larger amounts of blood-ridden catecholamines, segmental particularities of cardiac innervation and/or density of α-, and β-adrenergic receptors, pheochromocytoma, neurological chronic or acute comorbidities/catastrophies, coronary epicardial/microvascular vasospasm, and CMD.
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Affiliation(s)
- John E Madias
- From the Icahn School of Medicine at Mount Sinai, New York, NY, United States; Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States.
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Artusi N, Bussani R, Cominotto F. Pheochromocytoma-Induced Tako-Tsubo Syndrome: An Uncommon Presentation. J Emerg Med 2022; 63:e1-e6. [PMID: 35940981 DOI: 10.1016/j.jemermed.2022.04.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 04/02/2022] [Accepted: 04/23/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND A pheochromocytoma-induced tako-tsubo syndrome is a life-threatening complication of the rare endocrinological disease. The association between the two syndromes is known, though seldom reported in literature, but the categorization is still debated. CASE REPORT In this article, we provide two examples of clinical presentation of this rare condition, its diagnosis using point-of-care ultrasound, its management in the emergency department, and finally, a literature review. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: In case of a tako-tsubo syndrome-like myocardial dysfunction in a patient with unknown medical history, or recorded hypertensive or tachycardic peaks, a point-of-care ultrasound scan extended to the kidneys could help evaluate for a reversible underlying trigger cause such as pheochromocytoma.
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Affiliation(s)
- Nicola Artusi
- Emergency Department, University Hospital of Cattinara, Trieste, Italy
| | - Rossana Bussani
- Pathology Department, University Hospital of Cattinara, Trieste, Italy
| | - Franco Cominotto
- Emergency Department, University Hospital of Cattinara, Trieste, Italy
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Kvasnička J, Petrák O, Zelinka T, Klímová J, Kološov B, Novák K, Michalský D, Widimský J, Holaj R. Effect of adrenalectomy on remission of subclinical left ventricular dysfunction in patients with pheochromocytoma: a speckle-tracking echocardiography study. Endocr Connect 2021; 10:1538-1549. [PMID: 34734567 PMCID: PMC8679879 DOI: 10.1530/ec-21-0462] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Accepted: 11/03/2021] [Indexed: 12/04/2022]
Abstract
BACKGROUND Pheochromocytomas (PHEO) are tumours with the ability to produce, metabolize and secrete catecholamines. Catecholamines overproduction leads to the decrease of longitudinal function of the left ventricle (LV) measured by speckle-tracking echocardiography. Patients with PHEO have a lower magnitude of global longitudinal strain (GLS) than patients with essential hypertension. GLS normalization is expected after resolution of catecholamine overproduction. METHODS Twenty-four patients (14 females and 10 males) with a recent diagnosis of PHEO have been examined before and 1 year after adrenalectomy. An echocardiographic examination including speckle-tracking analysis with the evaluation of GLS and regional longitudinal strain (LS) in defined groups of LV segments (basal, mid-ventricular and apical) was performed. RESULTS One year after adrenalectomy, the magnitude of GLS increased (-14.3 ± 1.8 to -17.7 ± 1.6%; P < 0.001). When evaluating the regional LS, the most significant increase in the differences was evident in the apical segment compared to mid-ventricular and basal segments of LV (-5.4 ± 5.0 vs -1.9 ± 2.7 vs -1.6 ± 3.8; P < 0.01). CONCLUSIONS In patients with PHEO, adrenalectomy leads to an improvement of subclinical LV dysfunction represented by the increasing magnitude of GLS, which is the most noticeable in apical segments of LV.
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Affiliation(s)
- Jan Kvasnička
- 3rd Department of Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Ondřej Petrák
- 3rd Department of Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Tomáš Zelinka
- 3rd Department of Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Judita Klímová
- 3rd Department of Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Barbora Kološov
- 3rd Department of Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Květoslav Novák
- Department of Urology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - David Michalský
- 1st Department of Surgery, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Jiří Widimský
- 3rd Department of Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
| | - Robert Holaj
- 3rd Department of Medicine, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Praha, Czech Republic
- Correspondence should be addressed to R Holaj:
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Granberg D, Juhlin CC, Falhammar H. Metastatic Pheochromocytomas and Abdominal Paragangliomas. J Clin Endocrinol Metab 2021; 106:e1937-e1952. [PMID: 33462603 PMCID: PMC8063253 DOI: 10.1210/clinem/dgaa982] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Indexed: 12/20/2022]
Abstract
CONTEXT Pheochromocytomas and paragangliomas (PPGLs) are believed to harbor malignant potential; about 10% to 15% of pheochromocytomas and up to 50% of abdominal paragangliomas will exhibit metastatic behavior. EVIDENCE ACQUISITION Extensive searches in the PubMed database with various combinations of the key words pheochromocytoma, paraganglioma, metastatic, malignant, diagnosis, pathology, genetic, and treatment were the basis for the present review. DATA SYNTHESIS To pinpoint metastatic potential in PPGLs is difficult, but nevertheless crucial for the individual patient to receive tailor-made follow-up and adjuvant treatment following primary surgery. A combination of histological workup and molecular predictive markers can possibly aid the clinicians in this aspect. Most patients with PPGLs have localized disease and may be cured by surgery. Plasma metanephrines are the main biochemical tests. Genetic testing is important, both for counseling and prognostic estimation. Apart from computed tomography and magnetic resonance imaging, molecular imaging using 68Ga-DOTATOC/DOTATATE should be performed. 123I-MIBG scintigraphy may be performed to determine whether 131I-MIBG therapy is a possible option. As first-line treatment in patients with metastatic disease, 177Lu-DOTATATE or 131I-MIBG is recommended, depending on which shows best expression. In patients with very low proliferative activity, watch-and-wait or primary treatment with long-acting somatostatin analogues may be considered. As second-line treatment, or first-line in patients with high proliferative rate, chemotherapy with temozolomide or cyclophosphamide + vincristine + dacarbazine is the therapy of choice. Other therapies, including sunitinib, cabozantinib, everolimus, and PD-1/PDL-1 inhibitors, have shown modest effect. CONCLUSIONS Metastatic PPGLs need individualized management and should always be discussed in specialized and interdisciplinary tumor boards. Further studies and newer treatment modalities are urgently needed.
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Affiliation(s)
- Dan Granberg
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
| | - Carl Christofer Juhlin
- Department of Oncology-Pathology, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Department of Pathology and Cytology, Karolinska University Hospital, Stockholm, Sweden
| | - Henrik Falhammar
- Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
- Department of Breast, Endocrine Tumors and Sarcoma, Karolinska University Hospital, Stockholm, Sweden
- Department of Endocrinology, Metabolism and Diabetes, Karolinska University Hospital, Stockholm, Sweden
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Kvasnička J, Zelinka T, Petrák O, Rosa J, Štrauch B, Krátká Z, Indra T, Markvartová A, Widimský J, Holaj R. Catecholamines Induce Left Ventricular Subclinical Systolic Dysfunction: A Speckle-Tracking Echocardiography Study. Cancers (Basel) 2019; 11:cancers11030318. [PMID: 30845735 PMCID: PMC6468537 DOI: 10.3390/cancers11030318] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 02/24/2019] [Accepted: 02/28/2019] [Indexed: 12/23/2022] Open
Abstract
Background: Pheochromocytomas (PHEO) are tumors arising from chromaffin cells from the adrenal medulla, having the ability to produce, metabolize and secrete catecholamines. The overproduction of catecholamines leads by many mechanisms to the impairment in the left ventricle (LV) function, however, endocardial measurement of systolic function did not find any differences between patients with PHEO and essential hypertension (EH). The aim of the study was to investigate whether global longitudinal strain (GLS) derived from speckle-tracking echocardiography can detect catecholamine-induced subclinical impairments in systolic function. Methods: We analyzed 17 patients (10 females and seven males) with PHEO and 18 patients (nine females and nine males) with EH. The groups did not differ in age or in 24-h blood pressure values. Results: The patients with PHEO did not differ in echocardiographic parameters including LV ejection fraction compared to the EH patients (0.69 ± 0.04 vs. 0.71 ± 0.05; NS), nevertheless, in spackle-tracking analysis, the patients with PHEO displayed significantly lower GLS than the EH patients (−14.8 ± 1.5 vs. −17.8 ± 1.7; p < 0.001). Conclusions: Patients with PHEO have a lower magnitude of GLS than the patients with EH, suggesting that catecholamines induce a subclinical decline in LV systolic function.
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Affiliation(s)
- Jan Kvasnička
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Tomáš Zelinka
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Ondřej Petrák
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Ján Rosa
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Branislav Štrauch
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Zuzana Krátká
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Tomáš Indra
- Department of Nephrology, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Alice Markvartová
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Jiří Widimský
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
| | - Robert Holaj
- 3rd Department of Medicine, Centre for Hypertension, General University Hospital and 1st Faculty of Medicine, Charles University in Prague, Ovocný trh 5, 116 36 Prague 1, Czech Republic.
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