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Pillitteri M, Brogi E, Piagnani C, Bozzetti G, Forfori F. Perioperative management of Takotsubo cardiomyopathy: an overview. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2024; 4:45. [PMID: 39010210 PMCID: PMC11247845 DOI: 10.1186/s44158-024-00178-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 07/03/2024] [Indexed: 07/17/2024]
Abstract
Resembling the morphology of Japanese polyp vessels, the classic form of Takotsubo cardiomyopathy is characterized by the presence of systolic dysfunction of the mid-apical portion of the left ventricle associated with basal hyperkinesia. It is believed that this may be due to a higher density of β-adrenergic receptors in the context of the apical myocardium, which could explain the greater sensitivity of the apex to fluctuations in catecholamine levels.The syndrome is precipitated by significant emotional stress or acute severe pathologies, and it is increasingly diagnosed during the perioperative period. Indeed, surgery, induction of general anaesthesia and critical illness represent potential harmful trigger of stress cardiomyopathy. No universally accepted guidelines are currently available, and, generally, the treatment of TTS relies on health care personal experience and/or local practice. In our daily practice, anaesthesiologists can be asked to manage patients with the diagnosis of new-onset Takotsubo before elective surgery or an emergent surgery in a patient with a concomitant stress cardiomyopathy. Even more, stress cardiomyopathy can arise as a complication during the operation.In this paper, we aim to provide an overview of Takotsubo syndrome and to discuss how to manage Takotsubo during surgery and in anaesthesiologic special settings.
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Affiliation(s)
- Marta Pillitteri
- Department of Anaesthesia and Intensive Care, University of Pisa, Pisa, Italy
| | - Etrusca Brogi
- Neuroscience Intensive Care Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162, Milan, Italy.
| | - Chiara Piagnani
- Department of Anaesthesia and Intensive Care, University of Pisa, Pisa, Italy
| | - Giuseppe Bozzetti
- Department of Anaesthesia, Peri Operative Medicine and Critical Care, NHS Golden Jubilee, Glasgow, UK
| | - Francesco Forfori
- Department of Anaesthesia and Intensive Care, University of Pisa, Pisa, Italy
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Udemgba C, Bravo-Jaimes K, Mejia MO, Oli PR, Shrestha DB, Dawadi S, Kadariya D, Velarde G. Differences in clinical presentation and outcomes in pregnancy-associated Takotsubo Syndrome- A scoping review of the literature: Outcomes in pregnancy-associated Takotsubo. Curr Probl Cardiol 2024; 49:102175. [PMID: 37913927 DOI: 10.1016/j.cpcardiol.2023.102175] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Accepted: 10/28/2023] [Indexed: 11/03/2023]
Abstract
BACKGROUND Takotsubo syndrome (TS) during pregnancy and postpartum is rare but may lead to significant maternal and fetal morbidity. We compared clinical characteristics and prognosis according to [a] timing of presentation (pregnancy vs post-partum) and [b] modes of delivery (cesarean section vs vaginal delivery). METHODS Systematic review of articles published in PubMed, Scopus, Embase, and Medline databases from inception to July 30, 2023. Patient demographics, obstetric, electrocardiographic, laboratory, echocardiographic characteristics, and prognosis were summarized descriptively. RESULTS An initial database search identified 2162 articles, of which 81 studies were included in this review. TS during pregnancy can have emotional, obstetric, and metabolic triggers and has a higher proportion of adverse fetal outcomes when compared with women who developed TS postpartum. Women with TS after cesarean section had an earlier onset and higher proportion of anesthesia use when compared with those who developed TS after vaginal delivery. There were no differences regarding the degree of systolic dysfunction or the need for advanced therapies, including ventilator support, intra-aortic balloon pump, and extracorporeal membrane oxygenation among groups. CONCLUSIONS TS is associated with various triggers and adverse fetal outcomes when it develops during pregnancy than in the postpartum period. TS occurs more rapidly and with a more aggressive course after cesarean section than after vaginal delivery.
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Affiliation(s)
- Chinelo Udemgba
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | | | - Miluska O Mejia
- Division of Cardiology, Rochester General Hospital, Rochester, NY
| | - Prakash Raj Oli
- Department of Internal Medicine, Province Hospital, Birendranagar, Surkhet, Nepal
| | | | - Sagun Dawadi
- Department of Internal Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
| | - Dinesh Kadariya
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL
| | - Gladys Velarde
- Division of Cardiology, University of Florida College of Medicine, Jacksonville, FL.
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Harb DK, Abdelkareem W, Hazari K, Alali J, Fahad A, Al-Mekhlafi R, Ammar A. Takotsubo Syndrome (Broken-Heart Syndrome or Stress Cardiomyopathy) in an Epileptic Pregnant Woman: A Case Report. Cureus 2023; 15:e36308. [PMID: 37073190 PMCID: PMC10106267 DOI: 10.7759/cureus.36308] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/19/2023] Open
Abstract
Stress cardiomyopathy (Takotsubo syndrome) is a rare and transient cardiac dysfunction that has been reported in pregnant women with multiple triggering conditions. In general, those cases recovered from the acute cardiac insult within a few weeks. We report a 33-year-old 22 weeks pregnant woman, who presented with an episode of status epilepticus and subsequently developed acute heart failure. She had full recovery within three weeks and continued her pregnancy till term. She became pregnant again two years after this initial insult, remained asymptomatic with stable cardiac function and had normal vaginal delivery at term.
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A Case of Postpartum Takotsubo (Stress) Cardiomyopathy. Case Rep Cardiol 2022; 2022:4739742. [PMID: 35967747 PMCID: PMC9371808 DOI: 10.1155/2022/4739742] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 06/21/2022] [Accepted: 07/22/2022] [Indexed: 11/26/2022] Open
Abstract
Takotsubo (stress) cardiomyopathy (TCM) is usually triggered by psychological and/or physical stress. Most often, it is seen in postmenopausal women. Cases of TCM related to pregnancy are rare. We present a unique case of a 35-year-old, two-day postpartum female who was diagnosed with TCM.
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Autonomic Responses during Labor: Potential Implications for Takotsubo Syndrome. J Cardiovasc Dev Dis 2021; 8:jcdd8110152. [PMID: 34821705 PMCID: PMC8620927 DOI: 10.3390/jcdd8110152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2021] [Revised: 10/31/2021] [Accepted: 11/05/2021] [Indexed: 11/17/2022] Open
Abstract
Takotsubo syndrome is a serious complication of labor. Although the pathophysiologic role of excessive sympathetic activation is established in this process, concurrent vagal responses have not been adequately described. Moreover, it remains unclear whether autonomic activity depends on the mode of delivery. Here, we explored the hypothesis that the different management of cesarean and vaginal delivery may elicit diverse responses affecting both autonomic arms. For this aim, continuous electrocardiographic recording was performed in 20 women during labor, and non-invasive indices of sympathetic and vagal activity were compared between the two modes of delivery. We report sympathetic prevalence during cesarean delivery, caused by marked vagal withdrawal, whereas autonomic activity was rather stable during vaginal delivery. These differences may be attributed to the effects of anesthesia during cesarean delivery, along with the protective effects of oxytocin administration during vaginal delivery. Our results provide further insights on autonomic responses during labor that may prove useful in the prevention of complications, such as takotsubo syndrome.
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Mashak B, Hashemnejad M, Fakehi M, Heidary Z, Mirmajidi R, Ghaemi M. Atypical presentation of cardiomyopathy in a case of maternal mortality that was demonstrated as hypovolemic shock. Clin Case Rep 2021; 9:e05010. [PMID: 34721867 PMCID: PMC8543056 DOI: 10.1002/ccr3.5010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Revised: 08/28/2021] [Accepted: 10/11/2021] [Indexed: 01/19/2023] Open
Abstract
Periconceptional and prenatal care should be continued even during COVID-19 pandemics. Indeed, prevention and intervention programs for managing heart failure with aggressive resuscitation and invasive monitoring help to provide the best outcomes in cardiomyopathies. PPH may be associated with cardiac diseases and the resuscitation measures need modification to prevent maternal mortality.
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Affiliation(s)
- Banfsheh Mashak
- Kamali HospitalSchool of MedicineAlborz University of Medical SciencesKarajIran
| | - Maryam Hashemnejad
- Kamali HospitalSchool of MedicineAlborz University of Medical SciencesKarajIran
| | - Maliheh Fakehi
- Department of Gynecology and ObstetricsShahid Akbarabadi HospitalIran University of Medical SciencesTehranIran
| | - Zohreh Heidary
- Vali‐e‐Asr Reproductive Health Research CenterTehran University of Medical SciencesTehranIran
| | - Roghayyeh Mirmajidi
- Kamali HospitalSchool of MedicineAlborz University of Medical SciencesKarajIran
| | - Marjan Ghaemi
- Vali‐e‐Asr Reproductive Health Research CenterTehran University of Medical SciencesTehranIran
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DeFilippis EM, Haythe JH, Walsh MN, Kittleson MM. Intersection of Heart Failure and Pregnancy: Beyond Peripartum Cardiomyopathy. Circ Heart Fail 2021; 14:e008223. [PMID: 33980039 DOI: 10.1161/circheartfailure.120.008223] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Heart failure (HF) is a leading cause of morbidity and mortality in pregnant women in the United States. Although peripartum cardiomyopathy is the most common diagnosis for pregnant women with HF, women with preexisting cardiomyopathies and systolic dysfunction are also at risk as the hemodynamic demands of pregnancy can lead to decompensation, arrhythmia, and rarely death. The differential diagnosis of HF in pregnancy is broad and includes Takotsubo or stress cardiomyopathy, exacerbation of a preexisting cardiomyopathy, such as familial cardiomyopathy, hypertrophic cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, or left ventricular noncompaction. This review will explore the implications of pregnancy in women with preexisting cardiomyopathies and de novo HF, risk assessment and preconception planning, decisions about contraception, the safety of HF medications and implantable cardioverter-defibrillators during pregnancy, pregnancy in women with left ventricular assist devices and following heart transplantation.
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Affiliation(s)
- Ersilia M DeFilippis
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | - Jennifer H Haythe
- Division of Cardiology, New York Presbyterian-Columbia University Irving Medical Center (E.M.D., J.H.H.)
| | | | - Michelle M Kittleson
- Division of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
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Itagane M, Nakazato J, Kinjo M. Postpartum pheochromocytoma-induced takotsubo syndrome. BMJ Case Rep 2021; 14:e240098. [PMID: 33741570 PMCID: PMC7986668 DOI: 10.1136/bcr-2020-240098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/04/2021] [Indexed: 12/18/2022] Open
Abstract
A postpartum patient with acute-onset dyspnoea and hypotention, associated with reduced left ventricular function requiring intensive blood pressure control, was initially misdiagnosed as having peripartum cardiomyopathy. Her clinical symptoms rapidly resolved. Echocardiography revealed reversible left ventricular dysfunction with apical ballooning and coronary angiography was normal. Based on these findings, we diagnosed takotsubo syndrome. Over the next two months, the patient experienced repeated bouts of elevated sympathetic activity. On workup, we found an adrenal mass and elevated urine metanephrines. After adrenalectomy, histology confirmed pheochromocytoma. Our patient had the rare diagnosis of postpartum pheochromocytoma-induced takotsubo syndrome.
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Affiliation(s)
| | - Jun Nakazato
- Cardiology, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
| | - Mitsuyo Kinjo
- Medicine, Okinawa Chubu Hospital, Uruma, Okinawa, Japan
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Rawish E, Stiermaier T, Santoro F, Brunetti ND, Eitel I. Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 1-Pathophysiology and Diagnosis. J Clin Med 2021; 10:jcm10030479. [PMID: 33525539 PMCID: PMC7865728 DOI: 10.3390/jcm10030479] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2020] [Revised: 01/08/2021] [Accepted: 01/15/2021] [Indexed: 02/06/2023] Open
Abstract
First recognized in 1990, takotsubo syndrome (TTS) constitutes an acute cardiac condition that mimics acute myocardial infarction commonly in the absence of obstructive coronary artery disease; it is characterized by temporary left ventricular dysfunction, regularly in a circumferential apical, midventricular, or basal distribution. Considering its acute clinical presentation, coronary angiography with left ventriculography constitutes the gold standard diagnostic tool to exclude or confirm TTS. Frequently, TTS is related to severe emotional or physical stress and a subsequent increased adrenergic stimulation affecting cardiac function. Beyond clinical presentation, epidemiology, and novel diagnostic biomarkers, this review draws attention to potential pathophysiological mechanisms for the observed reversible myocardial dysfunction such as sympathetic overdrive-mediated multi-vessel epicardial spasms, microvascular dysfunction, the direct toxicity of catecholamines, lipotoxicity, and inflammation. Considering the long-term prognosis, further experimental and clinical research is indispensable to elucidate further pathophysiological mechanisms underlying TTS before randomized control trials with evidence-based therapeutic management can be performed.
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Affiliation(s)
- Elias Rawish
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) University Heart Center, 23538 Lübeck, Germany; (E.R.); (T.S.)
- DZHK (German Centre for Cardiovascular Research), 23538 Lübeck, Germany
| | - Thomas Stiermaier
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) University Heart Center, 23538 Lübeck, Germany; (E.R.); (T.S.)
- DZHK (German Centre for Cardiovascular Research), 23538 Lübeck, Germany
| | - Francesco Santoro
- Department of Medical & Surgery Sciences, University of Foggia, 71121 Foggia, Italy
| | - Natale D. Brunetti
- Department of Medical & Surgery Sciences, University of Foggia, 71121 Foggia, Italy
| | - Ingo Eitel
- Medical Clinic II (Cardiology/Angiology/Intensive Care Medicine) University Heart Center, 23538 Lübeck, Germany; (E.R.); (T.S.)
- DZHK (German Centre for Cardiovascular Research), 23538 Lübeck, Germany
- Correspondence: ; Tel.: +49-451-500-44501
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Wu HY, Cheng G, Liang L, Cao YW. Recurrent Takotsubo cardiomyopathy triggered by emotionally stressful events: A case report. World J Clin Cases 2021; 9:677-684. [PMID: 33553408 PMCID: PMC7829724 DOI: 10.12998/wjcc.v9.i3.677] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 11/24/2020] [Accepted: 12/06/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Takotsubo cardiomyopathy (TCM) is characterized by reversible left ventricular dysfunction triggered by emotional or physical stress. Only 1%-2% of patients with acute coronary syndrome are diagnosed with TCM. Although obstructive coronary artery disease is frequently considered to be the cause of chest pain, TCM should be considered in some clinical settings. In this case, clinicians did not make a timely and accurate diagnosis for TCM due to a lack of knowledge until the third hospitalization with a left ventriculogram.
CASE SUMMARY A 55-year-old postmenopausal woman had intermittent chest pain following emotionally stressful events three times in the past 3 years. Cardiac troponin levels increased after each instance of symptom onset. A transthoracic echocardiogram showed reversible left ventricular dysfunction. The patient underwent three coronary angiograms without evidence of coronary artery disease. A left ventriculogram was first performed at the third hospitalization and revealed apical akinesia with ballooning of the apical region and consistent hypercontractile basal segments. The diagnosis of TCM was confirmed. The patient was treated with an angiotensin-converting-enzyme inhibitor (perindopril) and a β-blocker (metoprolol). No complications occurred during the patient’s hospitalization. The patient was told to avoid stressful events. During the 9-mo follow-up visit, the patient was asymptomatic with an ejection fraction of 55%.
CONCLUSION Clinicians should be conscious of the possibility of TCM, especially in postmenopausal women presenting with clinical manifestations similar to acute coronary syndrome without coronary occlusion.
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Affiliation(s)
- Hao-Yu Wu
- Department of Cardiology, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
| | - Gong Cheng
- Department of Cardiology, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
| | - Lei Liang
- Department of Cardiology, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
| | - Yi-Wei Cao
- Department of Electrocardiology, Shaanxi Provincial People’s Hospital, Xi’an 710068, Shaanxi Province, China
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Tweet MS, Lewey J, Smilowitz NR, Rose CH, Best PJM. Pregnancy-Associated Myocardial Infarction: Prevalence, Causes, and Interventional Management. Circ Cardiovasc Interv 2020; 13:CIRCINTERVENTIONS120008687. [PMID: 32862672 PMCID: PMC7854968 DOI: 10.1161/circinterventions.120.008687] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Pregnancy-associated myocardial infarction is a primary contributor to maternal cardiovascular morbidity and mortality. Specific attention to the cause of myocardial infarction, diagnostic evaluation, treatment strategies, and postevent care is necessary when treating women with pregnancy-associated myocardial infarction. This review summarizes the current knowledge, consensus statements, and essential nuances.
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Affiliation(s)
- Marysia S Tweet
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN (M.S.T., P.J.M.B.)
| | - Jennifer Lewey
- Division of Cardiovascular Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia (J.L.)
| | - Nathaniel R Smilowitz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY (N.R.S.)
| | - Carl H Rose
- Department of Obstetrics and Gynecology, Division of Maternal Fetal Medicine, Mayo Clinic College of Medicine, Rochester, MN (C.H.R.)
| | - Patricia J M Best
- Department of Cardiovascular Diseases, Mayo Clinic College of Medicine and Science, Rochester, MN (M.S.T., P.J.M.B.)
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