A simple procedure in a complex patient: perioperative takotsubo cardiomyopathy

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.

Cardiovascular complications following medical termination of pregnancy: An updated review

BACKGROUND

Around 1 million cases of medical termination of pregnancy (MTP) take place yearly in the United States of America with around 2 percent of this population developing complications. The cardiovascular (CVD) complications occurring post MTP or after stillbirth is not very well described.

AIM

To help the reader better understand, prepare, and manage these complications by reviewing various cardiac comorbidities seen after MTP.

METHODS

We performed a literature search in PubMed, Medline, RCA, and google scholar, using the search terms "abortions" or "medical/legal termination of pregnancy" and "cardiac complications" or "cardiovascular complications".

RESULTS

The most common complications described in the literature following MTP were infective endocarditis (IE) (n = 16), takotsubo cardiomyopathy (TTC) (n = 7), arrhythmias (n = 5), and sudden coronary artery dissection (SCAD) (n = 4). The most common valve involved in IE was the tricuspid valve in 69% (n = 10). The most observed causative organism was group B Streptococcus in 81% (n = 12). The most common type of TTC was apical type in 57% (n = 4). Out of five patients developing arrhythmia, bradycardia was the most common and was seen in 60% (3/5) of the patients. All four cases of SCAD-P type presented as acute coronary syndrome 10-14 d post termination of pregnancy with predominant involvement of the right coronary artery. Mortality was only reported following IE in 6.25%. Clinical recovery was reported consistently after optimal medical management following all these complications.

CONCLUSION

In conclusion, the occurrence of CVD complications following pregnancy termination is infrequently documented in the existing literature. In this review, the most common CVD complication following MTP was noted to be IE and TTC.

Takotsubo Cardiomyopathy (TCM) After Uncomplicated Paraesophageal Hernia Repair: A Case Report and Review on Postoperative TCM

Takotsubo cardiomyopathy (TCM) is a rare stress-induced condition that appears rarely in suspected acute myocardial infarction cases. It causes unexplained left ventricular failure, but most cases are reversible with supportive treatment. In this report, we present the case of a 70-year-old female who developed acute hypotension after a laparoscopic Toupet fundoplication on postoperative day one, requiring care in the surgical intensive care unit. Following consultation with the cardiology service and further imaging and tests, she was diagnosed with TCM. This report outlines the potential mechanisms and management of TCM in the intensive care unit, emphasizing the importance of prompt diagnosis and treatment.

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.

Assessment and Prediction of Cardiovascular Contributions to Severe Maternal Morbidity

Severe maternal morbidity (SMM) refers to any unexpected outcome directly related to pregnancy and childbirth that results in both short-term delivery complications and long-term consequences to a women's health. This affects about 60,000 women annually in the United States. Cardiovascular contributions to SMM including cardiac arrest, arrhythmia, and acute myocardial infarction are on the rise, probably driven by changing demographics of the pregnant population including more women of extreme maternal age and an increased prevalence of cardiometabolic and structural heart disease. The utilization of SMM prediction tools and risk scores specific to cardiovascular disease in pregnancy has helped with risk stratification. Furthermore, health system data monitoring and reporting to identify and assess etiologies of cardiovascular complications has led to improvement in outcomes and greater standardization of care for mothers with cardiovascular disease. Improving cardiovascular disease-related SMM relies on a multipronged approach comprised of patient-level identification of risk factors, individualized review of SMM cases, and validation of risk stratification tools and system-wide improvements in quality of care. In this article, we review the epidemiology and cardiac causes of SMM, we provide a framework of risk prediction clinical tools, and we highlight need for organization of care to improve outcomes.