Aborted Sudden Cardiac Death in a Female Patient Presenting with Takotsubo-Like Cardiomyopathy due to Epicardial Coronary Vasospasm

TakoTsubo Syndrome: First an Acute Coronary Vasculitis and Then Prolonged Myocarditis?

Since its initial description by Japanese investigators 30 years ago, TakoTsubo Syndrome (TTS) has variously been regarded as a form of acute coronary syndrome and also as a form of cardiomyopathy (or more accurately, a myocarditis). There is actually good evidence that TTS embodies both of these concepts, and the main purpose of this review is to present data that they occur sequentially. The initial phase of the disorder (over perhaps the first 48 hours post onset of symptoms) represents a form of vasculitis, with associated damage to the endothelial glycocalyx and associated permeabilization of blood vessels. This is followed by a more prolonged phase of myocardial inflammation and oedema, associated with inflammatory activation and energetic impairment within the entire myocardium. Although this phase subsides after several months, it may be followed by longstanding impairment of myocardial function, reflecting residual fibrosis. Understanding of this gradual transition in TTS pathogenesis from vasculature towards myocardium remains an important limitation of patient management, especially as many patients are still told that their hearts have "recovered" within 1-2 weeks. A number of important uncertainties remain. These include development of specific early and ongoing therapeutic strategies to be used to match the sequential pathogenesis of TTS. "And so these men of Indostan Disputed loud and long, Each in his own opinion Exceeding stiff and strong, Though each was partly in the right, And all were in the wrong!" From: Six wise men of Hindustan.

Multivessel Coronary Artery Vasospasm-Induced Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy is associated with a constellation of cardiac findings including reversible left ventricular dysfunction and an acute triggering stressor. Epicardial coronary vasospasm is a rarely reported etiology for takotsubo cardiomyopathy, and its pathophysiologic mechanisms still remain incompletely understood. We present the case of a 54-year-old female with chest pain and ST-elevation myocardial infarction who was found to have takotsubo cardiomyopathy due to diffuse multivessel coronary artery vasospasm in the absence of obstructive coronary artery disease. To our knowledge, this is the first angiographically confirmed case of this rare phenomenon to be reported, as most literature involves focal, segmental, or single coronary artery involvement. Moreover, we review current literature and develop a discussion on the targeted treatment of vasospastic disease as part of the multimodal approach to the management of takotsubo syndrome.

A valuable cardiac magnetic resonance investigation after MINOCA/takotsubo Syndrome: a case report

Myocardial infarction with non-obstructive coronary arteries is a working diagnosis that includes takotsubo cardiomyopathy/syndrome (TTS). Cardiac magnetic resonance (CMR) is useful for establishing the underlying aetiology of myocardial infarction with non-obstructive coronary arteries during the acute phase, but its role in follow-up is less well established. A 35-year-old man with several cardiac risk factors presented 3 days after his sister's death with biochemical and clinical features of acute myocardial infarction without coronary artery obstruction on angiography but with diagnostic features of TTS on CMR, including oedema but no late gadolinium enhancement. Subsequent CMR 3 months later revealed left ventricular late gadolinium enhancement suggesting previous acute myocardial infarction. Although the initial diagnosis of TTS was robust according to established criteria, it remained uncertain whether the later ischaemic injury was related to an ischaemic event at presentation or occurred in the intervening period. Nevertheless, CMR may have an extended role in the follow-up of these patients and may reveal additional, actionable pathology.

Pathogenesis of Ventricular Arrhythmias and Its Effect on Long-Term Prognosis in Patients With Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TTC), also known as broken heart syndrome, stress cardiomyopathy (SCM), or apical ballooning syndrome, is a non-ischemic cardiac disease with an initial clinical presentation that is very similar to acute coronary syndrome (ACS). Ventricular arrhythmias (VAs) contribute significantly to an increase in the rates of death in patients with TTC, especially during the acute phase, in which patients with TTC are more susceptible to develop life-threatening arrhythmias (LTA) such as ventricular tachycardia (VT), ventricular fibrillation (VF), torsades de pointes (TdP), and sudden cardiac death (SCD). However, the pathophysiology of TTC and how VA occurs are still a mystery. We aim to review previous literature and discuss the possible mechanisms of VA in TTC patients.

VA usually complicates the acute phase of the disease and worsens the long-term prognosis. Alterations of repolarization (negative T wave, prolonged QTc) indicate a high risk of arrhythmic events (TdP, VT, VF, and SCD). Catecholamine effect on myocardial cells and myocardial edema can create a substrate for the development of VA. Some of the most commonly proposed mechanisms for the development of VA in patients with TTC are coronary vasospasm, myocardial stunning due to catecholamines, re-entry, and triggered activity. Further prospective studies, including a more significant number of patients, are required to understand the disease's pathophysiology better and improve LTA management in patients with TTC.

'Acute micro-coronary syndrome': detailed coronary physiology in a patient with Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC), otherwise known as stress cardiomyopathy, is characterised by acute, transient left ventricular systolic dysfunction with apical ballooning in the absence of obstructive epicardial coronary stenosis. The presentation of TC mimics that of acute myocardial infarction. More recently there has been a shift towards thinking of TC as a 'microvascular acute coronary syndrome'. Our case is of an 82-year-old woman who presented with TC mimicking acute anterior ST elevation myocardial infarction in the context of sepsis. Slow flow noted in the left anterior descending artery prompted us to perform coronary physiology. Her fractional flow reserve was 0.91, with an index of myocardial resistance of 117 and a coronary flow reserve of 1.6. In combination these results are indicative of microvascular coronary dysfunction in the absence of significant epicardial stenosis.