Dynamic left ventricular outflow tract obstruction in Takotsubo cardiomyopathy resulting in cardiogenic shock

Silent Threats of the Heart: A Case Series and Narrative Review on Suicide Left Ventricle Post-Aortic Valve Replacement in Patients with Dynamic LVOT Obstruction and Aortic Stenosis

Aortic stenosis (AS) is the most prevalent valvular heart disease in Europe and North America, with transcatheter aortic valve implantation (TAVI) revolutionizing its management. Hypertrophic left ventricle (HLV) frequently coexists with AS, complicating treatment due to the associated risk of left ventricular outflow tract (LVOT) obstruction, heart failure, and sudden death. A rare but severe post-aortic valve replacement (AVR) complication, termed "suicide left ventricle" (SLV), has emerged, necessitating further study. This report synthesizes current literature on SLV, its pathophysiology, and management strategies, alongside four patient case studies. The patients aged 79-87 years, underwent AVR for symptomatic AS with HLV. Post-AVR, all experienced severe complications, including dynamicLVOT gradients, systolic anterior motion (SAM) of the mitral valve, and severe hypotension, leading to death in two cases. One patient survived following surgical aortic valve replacement (SAVR) with surgical myectomy. One patient survived after TAVI. These cases highlight the critical importance of multidisciplinary Heart Team evaluations and personalized treatment plans in managing SLV. Despite advancements in AVR, SLV remains a complex, life-threatening condition, requiring an exhaustive and multifaceted approach for optimal patient outcomes. This report offers valuable insights into SLV occurrence and management from a clinical perspective.

Incidence of Takotsubo cardiomyopathy in patients with acute coronary syndrome: a single center retrospective analysis

BACKGROUND

Takotsubo cardiomyopathy (TTC) is an acute and usually reversible condition that often mimics the course of acute coronary syndrome (ACS), making it particularly challenging to differentiate, especially in the initial phases. In this study, we retrospectively analyzed the incidence, clinical course, examination results, and in-hospital mortality of TTC in patients with ACS hospitalized at our cardiology center from January 2018 to October 2023.

RESULTS

During the study period, a total of 3835 selective coronary angiograms were urgently performed at our facility, with a diagnosis of TTC established in 52 (1.35%) patients, the majority of whom were females-48 (93%), with an average age of 64.2 ± 10.2 years. Stress-induced mechanisms were identified in 36 (69%) patients. The most common symptom was chest pain (86.5%). Electrocardiographic changes primarily included ST-segment elevations (61.6%) and depressions (14%). The average left ventricular ejection fraction was 45.1 ± 8.3 (33-57%), typically with an echocardiographic pattern of apical ballooning dysfunction followed by midventricular dyskinesia. In-hospital mortality was zero.

CONCLUSIONS

TTC is a reversible condition with a low incidence of complications. Its occurrence in our patient cohort is lower compared to international registries. However, as demonstrated in this study, it is associated with significant in-hospital morbidity.

The many faces of takotsubo syndrome: A review

Takotsubo syndrome is a state of an acute heart failure featuring reversible left ventricular dysfunction. In recent years, the incidence of Takotsubo syndrome has risen 8-fold. In this case series and literature review, we present the rare presentations or complications of Takotsubo syndrome and highlight diagnostic or management strategies. We aim to raise the awareness on the pathologic spectrum of takotsubo syndrome for the clinicians encountering this challenging diagnosis.

Transcatheter interventions for left-sided valvular heart disease complicated by cardiogenic shock: a consensus statement from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the Association for Acute Cardiovascular Care (ACVC) and the ESC Working Group on Cardiovascular Surgery

Valvular heart disease (VHD) is one of the most frequent causes of heart failure (HF) and is associated with poor prognosis, particularly among patients with conservative management. The development and improvement of catheter-based VHD interventions have broadened the indications for transcatheter valve interventions from inoperable/high-risk patients to younger/lower-risk patients. Cardiogenic shock (CS) associated with severe VHD is a clinical condition with a very high risk of mortality for which surgical treatment is often deemed a prohibitive risk. Transcatheter valve interventions might be a promising alternative in this setting given that they are less invasive. However, supportive scientific evidence is scarce and often limited to small case series. Current guidelines on VHD do not contain specific recommendations on how to manage patients with both VHD and CS. The purpose of this clinical consensus statement, developed by a group of international experts invited by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) Scientific Documents and Initiatives Committee, is to perform a review of the available scientific evidence on the management of CS associated with left-sided VHD and to provide a rationale and practical approach for the application of transcatheter valve interventions in this specific clinical setting.

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.

Opposing forces of cardiogenic shock: left ventricular outflow obstruction, severe mitral regurgitation, and left ventricular dysfunction in Takotsubo cardiomyopathy

Rates of stress (Takotsubo) cardiomyopathy have increased during the coronavirus pandemic due to social stressors, even in patients who are not infected with the virus. At times, Takotsubo cardiomyopathy (TC) may present as cardiogenic shock. Herein, we present a case during the pandemic of shock from TC secondary to left ventricular outflow tract obstruction (LVOTO), mitral regurgitation (MR), and left ventricular (LV) dysfunction. The contrasting management strategy of LVOTO, MR, and LV failure was cause for clinical challenge, and we highlight the balance of treating these opposing forces.

Takotsubo Syndrome: Translational Implications and Pathomechanisms

Takotsubo syndrome (TTS) is identified as an acute severe ventricular systolic dysfunction, which is usually characterized by reversible and transient akinesia of walls of the ventricle in the absence of a significant obstructive coronary artery disease (CAD). Patients present with chest pain, ST-segment elevation or ischemia signs on ECG and increased troponin, similar to myocardial infarction. Currently, the known mechanisms associated with the development of TTS include elevated levels of circulating plasma catecholamines and their metabolites, coronary microvascular dysfunction, sympathetic hyperexcitability, inflammation, estrogen deficiency, spasm of the epicardial coronary vessels, genetic predisposition and thyroidal dysfunction. However, the real etiologic link remains unclear and seems to be multifactorial. Currently, the elusive pathogenesis of TTS and the lack of optimal treatment leads to the necessity of the application of experimental models or platforms for studying TTS. Excessive catecholamines can cause weakened ventricular wall motion at the apex and increased basal motion due to the apicobasal adrenoceptor gradient. The use of beta-blockers does not seem to impact the outcome of TTS patients, suggesting that signaling other than the beta-adrenoceptor-associated pathway is also involved and that the pathogenesis may be more complex than it was expected. Herein, we review the pathophysiological mechanisms related to TTS; preclinical TTS models and platforms such as animal models, human-induced pluripotent stem cell-derived cardiomyocyte (hiPSC-CM) models and their usefulness for TTS studies, including exploring and improving the understanding of the pathomechanism of the disease. This might be helpful to provide novel insights on the exact pathophysiological mechanisms and may offer more information for experimental and clinical research on TTS.

The Value of Fetuin-A as a Predictor to Identify Takotsubo Patients at Risk of Cardiovascular Events

INTRODUCTION

Takotsubo cardiomyopathy (TTC) remains a life-threatening disease with the risk of decompensated heart failure and arrhythmias. Valid markers for the prediction of outcome are unavailable. The novel biomarkers fetuin-A, matrix metalloproteinases-2 (MMP-2), myeloperoxidase (MPO), Syndecan-1 and CD40-L show promising results for risk stratification of cardiovascular patients. Nevertheless, clinical implementation has not been investigated in TTC patients.

METHODS

To investigate this issue, we evaluated clinical complications in 51 patients hospitalized for TTC and measured the serum levels of fetuin-A, MPO, MMP-2, Syndecan-1 and CD40-L within 24 h after admission.

RESULTS

Serum levels of Fetuin-A correlated inversely with the risk of cardiac decompensation and all cause complications within the acute phase of TTC. Fetuin-A levels over 190.1 µg/mL (AUC: 0.738, sensitivity 87.5%, specificity: 52.6%) indicate an acute phase of TTC without cardiac decompensation. Despite lower fetuin-A levels in patients with all cause complications, the combined endpoint remained slightly unmet (p = 0.058, AUC: 0.655). Patients with fetuin-A levels over 213.3 µg/mL are at risk of experiencing hemodynamic relevant rhythm disorders (AUC: 0.794; sensitivity: 75.0%, specificity: 79.1%). Other biomarkers failed to reveal a prognostic impact. Pro-BNP and hs troponin levels at admission did not predict adverse cardiac events.

CONCLUSION

Fetuin-A is a promising marker in our study and could be of benefit for the prediction of short-term adverse cardiac events in TTC patients. Therefore, fetuin-A might be of value to evaluate an individual's risk for complications within the acute phase of TTC and to individually choose the time of intensive care and hospitalization.