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Citro R, Bellino M, Merli E, Di Vece D, Sherrid MV. Obstructive Hypertrophic Cardiomyopathy and Takotsubo Syndrome: How to Deal With Left Ventricular Ballooning? J Am Heart Assoc 2023; 12:e032028. [PMID: 37889174 PMCID: PMC10727392 DOI: 10.1161/jaha.123.032028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2023]
Abstract
Currently, there are 2 proposed causes of acute left ventricular ballooning. The first is the most cited hypothesis that ballooning is caused by direct catecholamine toxicity on cardiomyocytes or by microvascular ischemia. We refer to this pathogenesis as Takotsubo syndrome. More recently, a second cause has emerged: that in some patients with underlying hypertrophic cardiomyopathy, left ventricular ballooning is caused by the sudden onset of latent left ventricular outflow tract obstruction. When it becomes severe and unrelenting, severe afterload mismatch and acute supply-demand ischemia appear and result in ballooning. In the context of 2 causes, presentations might overlap and cause confusion. Knowing the pathophysiology of each mechanism and how to determine a correct diagnosis might guide treatment.
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Affiliation(s)
- Rodolfo Citro
- Cardio‐Thorax‐Vascular DepartmentUniversity Hospital San Giovanni di Dio e Ruggi d’AragonaSalernoItaly
- Department of Vascular PhysiopathologyIRCCS NeuromedPozzilliItaly
| | - Michele Bellino
- Department of Medicine, Surgery and DentistryUniversity of SalernoSalernoItaly
| | - Elisa Merli
- Department of CardiologyOspedale per gli InfermiFaenzaItaly
| | - Davide Di Vece
- Department of CardiologyUniversity Hospital ZurichZurichSwitzerland
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Sherrid MV, Riedy K, Rosenzweig B, Ahluwalia M, Arabadjian M, Saric M, Balaram S, Swistel DG, Reynolds HR, Kim B. Hypertrophic cardiomyopathy with dynamic obstruction and high left ventricular outflow gradients associated with paradoxical apical ballooning. Echocardiography 2018; 36:47-60. [PMID: 30548699 DOI: 10.1111/echo.14212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 10/11/2018] [Accepted: 10/13/2018] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Acute left ventricular (LV) apical ballooning with normal coronary angiography occurs rarely in obstructive hypertrophic cardiomyopathy (OHCM); it may be associated with severe hemodynamic instability. METHODS, RESULTS We searched for acute LV ballooning with apical hypokinesia/akinesia in databases of two HCM treatment programs. Diagnosis of OHCM was made by conventional criteria of LV hypertrophy in the absence of a clinical cause for hypertrophy and mitral-septal contact. Among 1519 patients, we observed acute LV ballooning in 13 (0.9%), associated with dynamic left ventricular outflow tract (LVOT) obstruction and high gradients, 92 ± 37 mm Hg, 10 female (77%), age 64 ± 7 years, LVEF 31.6 ± 10%. Septal hypertrophy was mild compared to that of the rest of our HCM cohort, 15 vs 20 mm (P < 0.00001). An elongated anterior mitral leaflet or anteriorly displaced papillary muscles occurred in 77%. Course was complicated by cardiogenic shock and heart failure in 5, and refractory heart failure in 1. High-dose beta-blockade was the mainstay of therapy. Three patients required urgent surgical relief of LVOT obstruction, 2 for refractory cardiogenic shock, and one for refractory heart failure. In the three patients, surgery immediately normalized refractory severe LV dysfunction, and immediately reversed cardiogenic shock and heart failure. All have normal LV systolic function at 45-month follow-up, and all have survived. CONCLUSIONS Acute LV apical ballooning, associated with high dynamic LVOT gradients, may punctuate the course of obstructive HCM. The syndrome is important to recognize on echocardiography because it may be associated with profound reversible LV decompensation.
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Affiliation(s)
- Mark V Sherrid
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Katherine Riedy
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Barry Rosenzweig
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Monica Ahluwalia
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Milla Arabadjian
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Muhamed Saric
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Sandhya Balaram
- Mount Sinai St. Luke's, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Daniel G Swistel
- Hypertrophic Cardiomyopathy Program, Division of Cardiac Surgery, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Harmony R Reynolds
- Hypertrophic Cardiomyopathy Program, Division of Cardiology, New York University Langone Health, New York University School of Medicine, New York City, New York
| | - Bette Kim
- Mount Sinai West, Icahn School of Medicine at Mount Sinai, New York City, New York
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Maron BJ, Maron MS. The Remarkable 50 Years of Imaging in HCM and How it Has Changed Diagnosis and Management: From M-Mode Echocardiography to CMR. JACC Cardiovasc Imaging 2017; 9:858-872. [PMID: 27388665 DOI: 10.1016/j.jcmg.2016.05.003] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2016] [Revised: 05/02/2016] [Accepted: 05/12/2016] [Indexed: 11/28/2022]
Abstract
The almost 50-year odyssey of cardiac imaging in hypertrophic cardiomyopathy (HCM), revisited and described here, has been remarkable, particularly when viewed in the timeline of advances that occurred during a single generation of investigators. At each step along the way, from M-mode to 2-dimensional echocardiography to Doppler imaging, and finally over the last 10 years with the emergence of high-resolution tomographic cardiac magnetic resonance (CMR), evolution of the images generated by each new technology constituted a paradigm change over what was previously available. Together, these advances have transformed the noninvasive diagnosis and management of HCM in a number of important clinical respects. These changes include a more complete definition of the phenotype, resulting in more reliable clinical identification of patients and family members, defining mechanisms (and magnitude) of left ventricular outflow obstruction, and novel myocardial tissue characterization (including in vivo detection of fibrosis/scarring); notably, these advances afford more precise recognition of at-risk patients who are potential candidates for life-saving primary prevention defibrillator therapy. This evolution in imaging as applied to HCM has indelibly changed cardiovascular practice for this morphologically and clinically complex genetic disease.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Division of Cardiology, Boston, Massachusetts.
| | - Martin S Maron
- Hypertrophic Cardiomyopathy Institute, Tufts Medical Center, Division of Cardiology, Boston, Massachusetts
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Abstract
Treatments for hypertrophic cardiomyopathy are largely selected based on patient symptoms and echocardiographic findings. Moreover, all the advanced treatments for heart failure symptoms depend on such imaging for planning and monitoring response to therapy. Risk of sudden death correlates with maximum left ventricular (LV) wall thickness. Massive LV thickening of 30 mm or more is an indication for primary prevention of sudden death with an implanted defibrillator. In this review, we will underscore potential pitfalls in echocardiographic diagnosis. Also we will review, a newly appreciated pathophysiologic mechanism in obstruction dynamic systolic dysfunction due to gradient.
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Affiliation(s)
- Mark V Sherrid
- Division of Cardiology, St Luke's-Roosevelt Hospital Center, Columbia University, College of Physicians and Surgeons, 1000 10th Ave, New York City, NY 10019, USA.
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Cardim N, Campos P, Ferreira D, Carmelo V, Toste J, Trabulo M, Santos T, da Mariana S, Pereira Machado F, Roquette J. Are intraventricular gradients a cause of false positive treadmill exercise tests? REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2012. [DOI: 10.1016/j.repce.2012.01.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Sherrid MV, Balaran SK, Korzeniecki E, Chaudhry FA, Swistel DG. Reversal of Acute Systolic Dysfunction and Cardiogenic Shock in Hypertrophic Cardiomyopathy by Surgical Relief of Obstruction. Echocardiography 2011; 28:E174-9. [DOI: 10.1111/j.1540-8175.2011.01459.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Maron BJ, Maron MS, Wigle ED, Braunwald E. The 50-year history, controversy, and clinical implications of left ventricular outflow tract obstruction in hypertrophic cardiomyopathy from idiopathic hypertrophic subaortic stenosis to hypertrophic cardiomyopathy: from idiopathic hypertrophic subaortic stenosis to hypertrophic cardiomyopathy. J Am Coll Cardiol 2009; 54:191-200. [PMID: 19589431 DOI: 10.1016/j.jacc.2008.11.069] [Citation(s) in RCA: 161] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 11/12/2008] [Accepted: 11/12/2008] [Indexed: 12/17/2022]
Abstract
Dynamic obstruction to left ventricular (LV) outflow was recognized from the earliest (50 years ago) clinical descriptions of hypertrophic cardiomyopathy (HCM) and has proved to be a complex phenomenon unique in many respects, as well as arguably the most visible and well-known pathophysiologic component of this heterogeneous disease. Over the past 5 decades, the clinical significance attributable to dynamic LV outflow tract gradients in HCM has triggered a periodic and instructive debate. Nevertheless, only recently has evidence emerged from observational analyses in large patient cohorts that unequivocally supports subaortic pressure gradients (and obstruction) both as true impedance to LV outflow and independent determinants of disabling exertional symptoms and cardiovascular mortality. Furthermore, abolition of subaortic gradients by surgical myectomy (or percutaneous alcohol septal ablation) results in profound and consistent symptomatic benefit and restoration of quality of life, with myectomy providing a long-term survival similar to that observed in the general population. These findings resolve the long-festering controversy over the existence of obstruction in HCM and whether outflow gradients are clinically important elements of this complex disease. These data also underscore the important principle, particularly relevant to clinical practice, that heart failure due to LV outflow obstruction in HCM is mechanically reversible and amenable to invasive septal reduction therapy. Finally, the recent observation that the vast majority of patients with HCM have the propensity to develop outflow obstruction (either at rest or with exercise) underscores a return to the characterization of HCM in 1960 as a predominantly obstructive disease.
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Affiliation(s)
- Barry J Maron
- Hypertrophic Cardiomyopathy Center, Minneapolis Heart Institute Foundation, Minneapolis, Minnesota 55407, USA.
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