Ventricular septal perforation in a patient with takotsubo cardiomyopathy

ST-segment elevation in V1-4 in takotsubo cardiomyopathy with ventricular septal perforation: A case report and literature review

Background

Takotsubo cardiomyopathy (TCM) is a nonischemic cardiomyopathy characterized by chest pain, typically manifesting transient left ventricular (LV) apical akinesis, and ischemic electrocardiographic changes, mimicking acute coronary syndrome (ACS). Although ventricular septal perforation (VSP) is a rare complication of TCM, it is potentially life-threatening if left untreated. Whether the conventional electrocardiographic criteria for TCM are beneficial, even in patients of TCM with VSP, remains unclear.

Case presentation

An 87-year-old woman was admitted for worsening dyspnea. Elevated serum cardiac enzyme levels, LV dysfunction on echocardiography, and ST-segment elevation in leads V1-4 on electrocardiogram were initially suggestive of ACS. An emergency coronary angiography revealed 90 % focal stenosis of the mid-portion of the right coronary artery (RCA) with Thrombolysis in Myocardial Infarction flow grade 2. However, left ventriculography revealed LV apical ballooning with a coexisting left-to-right shunting, which was beyond single RCA distributions, leading to a final diagnosis of TCM with VSP. Repeat echocardiography confirmed VSP and right ventricular involvement with severe pulmonary hypertension. Following successful percutaneous coronary intervention with a drug-eluting stent for RCA stenosis, the patient was managed with medical treatment without surgical intervention. Eventually, VSP and associated pulmonary hypertension markedly improved along with the normalization of the patient's cardiac structure and function. The patient's clinical course was uneventful at the 1-year follow-up.

Conclusions

Herein, we describe the case of TCM with VSP that we successfully managed with medical treatments. Our case highlights the significance of elucidating this rare complication of TCM, pitfalls of the conventional electrocardiographic diagnostic criteria for TCM, and potential of this unique electrocardiographic pattern for identifying TCM-associated VSP.

Cardiac rupture as a life-threatening outcome of Takotsubo syndrome: A systematic review

BACKGROUND

Takotsubo syndrome (TS) is a reversible cause of heart failure; however, a minority of patients can develop serious complications, including cardiac rupture (CR).

OBJECTIVES

Analyze case reports of CR related to TS, detailing patient characteristics to uncover risk factors and prognosis for this severe complication.

METHODS

We conducted a systematic search of MEDLINE and Embase databases to identify case reports of patients with TS complicated by CR, from inception to October 2023.

RESULTS

We included 44 subjects (40 females; 4 males) with a median age of 75 (IQR 71-82) years, of White/Caucasian (61%) or East Asian/Japanese (39%) ethnicity. An emotional trigger was present in 15 (34%) subjects and an apical ballooning pattern was observed in all cases (100%). ST-segment elevation was reported in 39 (93%) of 42 cases, with the anterior myocardial segments (37 [88%]) being the most compromised, followed by lateral (26 [62%]) and inferior (14 [33%]) segments. The median time to cardiac rupture was 48 (5-120) hours since admission, with the left ventricular free wall (25 [57%]) being the most frequent site of perforation. Surgery was attempted in 16 (36%) cases, and 28 (64%) patients did not survive.

CONCLUSIONS

CR related to TS is a rare complication associated with high mortality and affecting elderly females, specially from White/Caucasian or East Asian/Japanese descent, presenting with anterior or lateral ST-segment elevation, and an apical ballooning pattern. Although data is limited and additional prospective studies are needed, the awareness of this life-threatening complication is crucial to early identify high-risk patients.

CONDENSED ABSTRACT

Cardiac rupture is a rare complication of Takotsubo syndrome. We conducted a systematic review of cases complicated by cardiac rupture, and we identified 44 subjects (40 females and 4 males) with a median age of 75 (IQR 71-82) years, of White/Caucasian (61%) or East Asian/Japanese (39%) ethnicity, all with an apical ballooning pattern (100%). The median time to cardiac rupture was 48 (5-120) hours since admission, with the left ventricular free wall (25 [57%]) being the most frequent site of perforation. Surgery treatment was attempted in 16 (36%) cases, and 28 (64%) patients did not survive.

Biventricular Takotsubo syndrome complicated with cardiogenic shock and ventricular septal rupture: a case report

Background

Takotsubo syndrome (TTS) mimics acute coronary syndromes but can lead to serious cardiac complications, emphasizing the need for improved understanding and management.

Case summary

We describe a TTS case presented with cardiogenic shock due to ventricular septal rupture (VSR). Successful treatment involved mechanical circulatory support followed by VSR surgical closure.

Discussion

Ventricular septal rupture is the rarest and deadliest complication associated with TTS. Prompt recognition and a multidisciplinary approach are crucial to achieve the best possible outcome.

Takotsubo Syndrome and Sudden Cardiac Death

Takotsubo syndrome (TTS), triggered by intense emotional or physical stress, occurring most commonly in post-menopausal women, presents as an ST-elevation myocardial infarction (MI). Cardiovascular complications occur in almost half the patients with TTS, and the inpatient mortality is comparable to MI (4-5%) owing to cardiogenic shock, myocardial rupture, or life-threatening arrhythmias. Thus, its prognosis is not as benign as previously thought, as it may cause mechanical complications (cardiac rupture) and potentially lethal arrhythmias and sudden cardiac death (SCD). Similar to MI, some patients may perish before reaching the hospital due to out-of-hospital cardiac arrest; this may lead to underestimation of the actual SCD risk. Furthermore, after discharge, some patients may develop late SCD and/or TTS recurrence that may result in SCD. There are risk factors for SCD in TTS patients, such as severe/persistent QT-interval prolongation inciting torsade-de-pointes, other ECG abnormalities (diffuse giant negative T-waves, widened QRS-complex), bradyarrhythmias, comorbidities, concurrent obstructive coronary artery disease or vasospasm, male gender, older age, severe left ventricular dysfunction, and use of sympathomimetic drugs. All these issues are herein reviewed, case reports/series and data from large cohort studies and meta-analyses are analyzed, risk factors are tabulated, and proarrhythmic effects and management strategies are discussed and pictorially illustrated.

Cardiac Rupture-The Most Serious Complication of Takotsubo Syndrome: A Series of Five Cases and a Systematic Review

Background: The most serious complication of the acute Takotsubo phase is a myocardial perforation, which is rare, but it usually results in the death of the patient. Methods: In the years 2008–2020, 265 patients were added to the Podlasie Takotsubo Registry. Cardiac rupture was observed in five patients (1.89%), referred to as the Takotsubo syndrome with complications of cardiac rupture (TS+CR) group. The control group consisted of 50 consecutive patients with uncomplicated TS. The diagnosis of TS was based on the Mayo Clinic Criteria. Results: Cardiac rupture was observed in women with TS aged 74–88 years. Patients with TS and CR were older (82.20 vs. 64.84; p = 0.011), than the control group, and had higher troponin, creatine kinase, aspartate aminotransferase, and blood glucose levels (168.40 vs. 120.67; p = 0.010). The TS+CR group demonstrated a higher heart rate (95.75 vs. 68.38; p < 0.0001) and the Global Registry of Acute Coronary Events (GRACE) scores (186.20 vs. 121.24; p < 0.0001) than the control group. In patients with CR, ST segment elevation was recorded significantly more often in the III, V4, V5 and V6 leads. Left ventricular free wall rupture was noted in four patients, and in one case, rupture of the ventricular septum. In a multivariate logistic regression, the factors that increase the risk of CR in TS were high GRACE scores, and the presence of ST segment elevation in lead III. Conclusions: Cardiac rupture in TS is rare but is the most severe mechanical complication and is associated with a very high risk of death. The main risk factors for left ventricular perforation are female gender, older age, a higher concentration of cardiac enzymes, higher GRACE scores, and ST elevations shown using electrocardiogram (ECG).

[Endovascular closure of a ventricular septal defect from Takotsubo Syndrome]

Takotsubo Syndrome is a transient condition characterized by left ventricular systolic dysfunction. Although the prognosis is excellent in most cases, rare cases of serious complications can occur. We present a case of a 81-year - old woman with Takotsubo Syndrome complicated by ventricular septal rupture that was successfully closed with an occluder Occlutech with good immediate and long - term outcomes.

Medically Treated Ventricular Septal Perforation Caused by Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy is a common disease, but Takotsubo cardiomyopathy complicated by ventricular septal perforation is very rare. We describe the case of a 92-year-old male who had Takotsubo cardiomyopathy complicated by ventricular septal perforation. We treated the patient medically without surgical or catheter interventions. In three weeks, his abnormal wall motion recovered completely, whereas the ventricular septal perforation remained open. He was ambulatory, subsequently discharged, and had been uneventful for one year. In this manuscript, we discuss the importance of non-invasive management for Takotsubo cardiomyopathy complicated by ventricular septal perforation.

Takotsubo Cardiomyopathy-Induced Cardiac Free Wall Rupture: A Case Report and Review of Literature

Takotsubo cardiomyopathy (TCM) is an acquired form of cardiomyopathy that is commonly seen among post-menopausal women. It is characterized by left ventricular apical ballooning, electrocardiographic changes and mild elevation of cardiac enzymes in the absence of significant coronary artery stenosis. TCM usually has benign course. However, on rare instance, it can result in life-threatening and fatal complications including acute cardiogenic shock, ventricular arrhythmias and ventricular wall rupture. We herein report a case of a 77-year-old female who developed TCM complicated with massive pericardial effusion and cardiac arrest. The patient died and autopsy revealed normal coronaries with a slit-like rupture on the antero-apical surface of the heart extending into the papillary muscle. The clinical course, labs and angiographic findings preceding the cardiac rupture will be outlined. A thorough literature review including review of 14 previously reported case reports of TCM complicated with cardiac rupture will be included.

Ventricular Septal Perforation: A Rare but Life-Threatening Complication Associated with Takotsubo Syndrome

A 71-year-old woman was admitted with dyspnea. An electrocardiogram revealed ST-segment elevation, and echocardiography showed akinesis in the left ventricular apex with hyperkinesis of the base. Coronary angiography revealed no stenosis, and left ventriculography indicated ballooning of the left ventricular apex and apical ventricular septal perforation. We diagnosed the patient with Takotsubo syndrome complicated by ventricular septal perforation, which was surgically repaired. Although ventricular septal perforation is recognized as a life-threatening complication after acute myocardial infarction, it can also occur after Takotsubo syndrome. The early recognition and management of this condition can help prevent morbidity and mortality.

Mending a Broken Heart: Treatment of Stress-Induced Heart Failure after Solid Organ Transplantation

Stress-induced heart failure, also known as Broken Heart Syndrome or Takotsubo Syndrome, is a phenomenon characterized as rare but well described in the literature, with increasing incidence. While more commonly associated with postmenopausal women with psychiatric disorders, this entity is found in the postoperative patient. The nonischemic cardiogenic shock manifests as biventricular failure with significant decreases in ejection fraction and cardiac function. In a review of over 3000 kidney and liver transplantations over the course of 17 years within two transplant centers, we describe a series of 7 patients with Takotsubo Syndrome after solid organ transplantation. Furthermore, we describe a novel approach of successfully treating the transient, though potentially fatal, cardiogenic shock with a percutaneous ventricular assistance device in two liver transplant patients, while treating one kidney transplant patient medically and the remaining four liver transplant patients with an intra-aortic balloon pump. We describe our experience with Takotsubo's Syndrome and compare the three modalities of treatment and cardiac augmentation. Our series is novel in introducing the percutaneous ventricular assist device as a more minimally invasive intervention in treating nonischemic heart failure in the solid organ transplant patient, while serving as a comprehensive overview of treatment modalities for stress-induced heart failure.

'Broken-heart' syndrome: ventricular septal perforation in a takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a form of acute left ventricular dysfunction usually reversible and with favorable prognosis. Ventricular septal perforation (VSP) is a very rare life-threatening complication. Percutaneous closure of VSP, despite being challenging, is a possible alternative to surgical repair. We present the first case of an 84-year-old patient with a TTC-related VSP treated by percutaneous approach. The case highlights the need of reconsidering the worldwide accepted consideration of TTC as benignant and allows some speculations on the optimal management of VSP in terms of timing, patient selection and possible alternative interventions.

Rare Complication of Takotsubo Cardiomyopathy: Ventricular Septal Perforation with Septal Dissection

We describe a rare case of takotsubo cardiomyopathy complicated by acute ventricular septal perforation with ventricular septal dissection. The ventricular perforation was successfully closed by repairing the dissecting site with a bovine pericardial patch.

Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology

Takotsubo syndrome is an acute reversible heart failure syndrome that is increasingly recognized in modern cardiology practice. This Position Statement from the European Society of Cardiology Heart Failure Association provides a comprehensive review of the various clinical and pathophysiological facets of Takotsubo syndrome, including nomenclature, definition, and diagnosis, primary and secondary clinical subtypes, anatomical variants, triggers, epidemiology, pathophysiology, clinical presentation, complications, prognosis, clinical investigations, and treatment approaches. Novel structured approaches to diagnosis, risk stratification, and management are presented, with new algorithms to aid decision-making by practising clinicians. These also cover more complex areas (e.g. uncertain diagnosis and delayed presentation) and the management of complex cases with ongoing symptoms after recovery, recurrent episodes, or spontaneous presentation. The unmet needs and future directions for research in this syndrome are also discussed.

Takotsubo Syndrome - Stress-induced Heart Failure Syndrome

Takotsubo syndrome has been established as an entity in the past 30 years, particularly with the introduction of interventional angiography for investigation of chest pain. Typically, it occurs in middle-aged females as a response to a stressful event, such as bad news, death, accident, natural disaster, etc. but there is not always a specific trigger. Takotsubo mimics acute myocardial infarction with electrocardiogram changes and elevated troponins. On interventional angiography the coronary arteries are normal with typical apical ballooning of the left ventricle. This feature led to its descriptive name, given by Japanese cardiologists, as the left ventricle resembles a lobster trap with a narrow neck extending into a round ventricle. This leads to a reduction in cardiac function. Takotsubo is believed to be a response to catecholamine release following a stressful event resulting in temporary myocardial damage. It usually has a benign course with spontaneous return of cardiac function. However it may recur and in a small percentage of patients can result in sudden cardiac death with arrhythmia, acute myocardial infarction and cardiac rupture. It is usually treated symptomatically depending on the severity of presentation.

Critical takotsubo cardiomyopathy complicated by ventricular septal perforation

An 81-year-old woman was admitted with chest pain. An electrocardiogram demonstrated ST segment elevation in leads II, III and aVF, and echocardiography revealed left ventricular apical asynergy with a left-to-right ventricular shunt. Meanwhile, emergent coronary angiography showed no significant coronary artery stenosis, whereas left ventriculography indicated apical ballooning and a left-to-right ventricular shunt. We therefore diagnosed the patient with Takotsubo cardiomyopathy complicated by ventricular septal perforation and cardiogenic shock. An electrocardiogram disclosed a prolonged QT interval over time, and the patient became hemodynamically stable under treatment with inotropes; however, she suddenly developed fatal ventricular fibrillation three days after hospitalization. Takotsubo cardiomyopathy complicated by ventricular septal perforation is a critical condition that requires careful monitoring.

J wave and fragmented QRS formation during the hyperacute phase in Takotsubo cardiomyopathy

BACKGROUND

 The J wave and fragmented QRS (fQRS) on electrocardiography are suggested to be closely related to cardiac arrhythmogenesis. Takotsubo cardiomyopathy (TTC) occasionally causes fatal cardiac conditions including life-threatening ventricular arrhythmia. There has been, however, only 1 case report describing the J wave in TTC, and fQRS has not been reported thus far in relation to clinical courses and prognosis.

METHODS AND RESULTS

 J wave and fQRS formation were investigated in 31 consecutive patients with TTC. Nine patients (29%) had J waves and/or fQRS (group A), whereas the remaining 22 did not (group B). The J wave (4 patients), fQRS (4 patients), or both (1 patient) appeared transiently during the hyperacute phase. Left ventricular ejection fraction was significantly lower in group A. Summed defect score of single-photon emission computed tomography using iodine 123 beta-methyl-p-iodophenyl-pentadecanoic acid, and creatine kinase MB isozyme (CKMB) were significantly higher in group A. On multivariate analysis CKMB was a significant indicator of J wave or fQRS. Moreover, the J wave was a significant indicator for cardiac death and/or ventricular tachyarrhythmia (odds ratio, 11.5; P=0.026).

CONCLUSIONS

 Patients with TTC frequently had J waves and/or fQRS during the hyperacute phase, and which were associated with myocardial damage. J wave was also an indicator for cardiac death and/or ventricular tachyarrhythmia. J waves and fQRS may be useful markers for myocardial damage. 

Initial clinical presentation of Takotsubo cardiomyopathy with-a focus on electrocardiographic changes: A literature review of cases

AIM: To review the initial presentation and demonstrate the importance of Takotsubo cardiomyopathy.

METHODS: A PubMed search using the terms “Takotsubo cardiomyopathy (TC)” and “apical ballooning syndrome” yielded 211 publications. Only those that were relevant were fully reviewed. The gender, age, precipitating stressor, main complaint at presentation, electrocardiogram (ECG) at admission and serum cardiac markers of patients diagnosed with TC, were extracted as available. The data were organized in tables and graphics, and the incidence of the disorder was calculated and analyzed.

RESULTS: A total of 250 clinical cases were examined. The predominant gender that was affected was female, with a prevalence of 87.5%. The mean age of presentation was 64 ± 14 years. The cases were divided by age into 10-year intervals. The age interval of 60-69 years showed the highest frequency of TC, accounting for 79 cases. The most common precipitating stressor was physical (50% of cases). Chest pain was the primary complaint at presentation (58.8% of cases) followed by dyspnea (30% of cases). The ST segment changes category was the most common (60%), followed by T wave changes (39.6%). Of the 60% of cases with ST segment changes, 12% had concomitant T wave changes. This means that for 27.6% of the cases, the primary abnormality in the ECG was T wave changes; 87.6% of cases with TC had a change in the ST segment, in the T wave or in both. The percentage of ECGs presenting with changes in the anterior wall was 54.4% (35.6% of ST segment elevation + 1.6% of ST segment depression + 17.2% of T wave inversion). The percentage of patients presenting with changes in the lateral segment of the heart was 46.8%, while the percentage of patients with changes in the inferior heart was 21.6% and the percentage of patients with changes in the apical region was only 16%. The prevalence of elevated creatinine kinase and/or troponin on initial presentation was 89.3%.

CONCLUSION: It is essential that every physician consider Takotsubo cardiomyopathy as a possible differential diagnosis when a patient is classified with acute coronary syndrome. To do so, it is necessary to know the clinical presentation of this syndrome in its early stages.

Cardiac rupture in takotsubo cardiomyopathy: a systematic review

BACKGROUND

Takotsubo cardiomyopathy (TSC) and its complications, such as cardiac rupture (CR), are increasingly being reported in the literature. CR is associated with rapid clinical decline and is uniformly fatal if not surgically repaired. To identify patients who developed CR we performed an analysis of all available indexed cases in the literature and compared them with a control group of patients with TSC without rupture.

HYPOTHESIS

Takotsubo cardiomyopathy patients with cardiac rupture do not differ significantly from those without rupture.

METHODS

MEDLINE (2009) was searched for all TSC case reports with CR. Eleven case reports were identified. Using a random sampling method, we selected 12 case reports of TSC without rupture (control). We included our patient with TSC with rupture as the 12th case of TSC cohort with CR (CR group). Demographic and clinical characteristics were compared between CR group and control.

RESULTS

All patients in the TSC group with rupture were female and were significantly older than controls. TSC group with rupture had significantly higher frequency of ST elevation in lead II and absence of T-wave inversion in lead V5 on hospital admission than controls. Mean ejection fraction, systolic blood pressure, and double product, a measure of oxygen demand, was significantly higher in the rupture group compared to controls. The CR group was associated with less frequent use of β-blocker as compared to controls.

CONCLUSIONS

CR as a complication of TSC could be more common than recognized. Higher double product and ejection fraction suggest higher fluctuation of intracardiac pressure and may cause CR in TSC. Use of β blockers in TSC may provide protection against CR.

Outcomes of patients with stress-induced cardiomyopathy diagnosed by echocardiography in a tertiary referral hospital

BACKGROUND

Because stress-induced cardiomyopathy (SIC) is increasingly being observed during routine daily practice, we sought to explore the clinical features and factors that determine the outcome of SIC in a tertiary referral hospital.

METHODS

Patients with typical left ventricular (LV) takotsubo (apical ballooning) or inverted takotsubo on 2-dimensional echocardiography were prospectively enrolled, and their clinical data were analyzed.

RESULTS

Over a 63-month period, 56 consecutive patients (median age and interquartile range=64 years [52-74 years]) were identified. Women comprised 79% (44/56) of all patients. The triggering events were acute medical illness, including sepsis and hypoxemia in 29 patients (52%, group A), in-hospital surgery/procedure in 17 patients (30%, group B), and emotional stress in 10 patients (18%, group C). Chest pain was more frequently observed in group C (50%) than in groups A (14%) and B (6%) (P=.021), whereas dyspnea was the presenting symptom in groups A and B. Typical takotsubo and inverted takotsubo were observed in 48 and 8 patients, with a median ejection fraction of 33%. Other abnormalities included dynamic LV outflow tract obstruction (n=2), LV thrombus (n=2), and right ventricular dysfunction (n=12). Nine deaths (16%) occurred during hospitalization. The groups did not differ in mortality. The Acute Physiology and Chronic Health Evaluation II score (odds ratio 1.405; 95% confidence interval, 1.091-1.810; P=.009) and absence of LV function recovery within 1 week (ejection fraction<50%) (odds ratio 14.080; 95% confidence interval, 1.184-167.475; P=.036) were independent factors associated with mortality. During clinical follow-up up to 6 months, 3 more patients died, 2 of whom had recurrences of SIC.

CONCLUSIONS

SIC in a tertiary referral hospital was mainly associated with physical stressors and characterized by diverse clinical presentations, high mortality, and occasional fatal recurrences.

Tako-tsubo cardiomyopathy complicated by ventricular septal perforation and septal dissection

Tako-tsubo cardiomyopathy is a form of reversible left ventricular dysfunction, with a clinical and electrocardiographic picture of acute myocardial infarction in the absence of significant coronary disease. The precise clinical features and etiologic basis of this syndrome remain unclear, although an association with emotional or stressful triggers has been recognized. We describe the first case of this syndrome complicated with a ventricular septal perforation and dissection.

A case of Takotsubo cardiomyopathy complicated by ventricular septal perforation

The patient was a 73-year-old female who developed chest pain and dyspnea 16 days after her husband passed away. ST segment elevation was detected on V2-5 by electrocardiography and emergency coronary arteriography was done for suspected acute myocardial infarction. No coronary arterial stenosis was present and ventricular septal perforation and takotsubo cardiomyopathy were diagnosed by left ventriculography. The perforation was closed and the patient was discharged 23 days after surgery. This patient had a very rare case of takotsubo cardiomyopathy, which was complicated by ventricular septal perforation and was saved by surgical treatment.

Striking observations during emergency catecholamine treatment of cardiac syncope in a patient with initially unrecognized takotsubo cardiomyopathy

A case is presented of initially unrecognized takotsubo cardiomyopathy with a dramatic clinical course after emergency catecholamine treatment for circulatory support during stress-induced cardiac syncope followed by complete recovery of cardiac function after catecholamine withdrawal and starting beta-blocker therapy. Echocardiography including 2D-strain imaging suggested that the left ventricle (LV) wall motion abnormality was mainly the consequence of geometry-induced regional differences in wall stress (progressively amplified by catecholamines), which might be another possible pathophysiological mechanism involved in the development of LV dysfunction in takotsubo cardiomyopathy. This case also suggests that in emergency, before coronary angiography is possible, echocardiography can be helpful for initial therapeutic decisions, especially to avoid emergency inotropic therapy in such patients.

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a disease in which patients present with signs and symptoms mimicking an acute coronary syndrome and, thus, undergo cardiac catheterization. At the time of catheterization, however, no critical coronary lesions are found. Most of these patients have a characteristic left ventriculogram and recent history of a preceding stressor. While the acute phase of the illness can lead to ventricular tachyarrhythmias and possibly even death, a key feature of this syndrome in the majority of patients is its generally benign course and reversibility in myocardial dysfunction over a period of days to weeks. The pathophysiology of Takotsubo cardiomyopathy remains unclear. Optimal long-term medical therapy has not been well established at this time, since the etiology of the disease process remains a source of debate.

[Takotsubo cardiomyopathy: transient apical dysfunction of the left ventricle]

Transient apical dysfunction syndrome, ballooning or Takotsubo cardiomyopathy is a recently described syndrome. It is a disease with a partially known mechanism, characterized by the morphology adopted by the left ventricle secondary to hypokinesis and dyskinesis of the apical segments and hypercontractibility of the basal segments. In most of the cases published, it is a syndrome with ST segment elevation in the precordial leads, whose presentation form is also thoracic pain or dyspnea, with the possible existence of moderate elevation of cardiac biomarkers. On the contrary to the acute coronary syndrome, patients with left ventricle dysfunction do not have atherothrombotic disease in the coronary arteries. Furthermore, the alterations described have a reversible character. Some diagnostic clinical criteria have been proposed and there is presently some controversy on them and on the complementary examination needed to diagnose it.

A case of takotsubo cardiomyopathy associated with epileptic seizure: reversible left ventricular wall motion abnormality and ST-segment elevation

A 59-year-old woman was admitted for consciousness disturbance. She had a history of endocranial operation for astrocytoma. Her electrocardiogram showed ST-segment elevation indicative of acute myocardial infarction. Emergency coronary angiography showed normal coronary arteries, whereas left ventriculography showed extensive severe hypokinesis in the anteroseptal and apical segments. Electroencephalography showed slow sharp wave activity from the left frontal lobe to the temporal lobe, and she was diagnosed as having status epilepticus. This is a rare case of takotsubo cardiomyopathy associated with epileptic seizure. Acute myocardial ischemia caused by impaired coronary microcirculation induced by abnormal catecholamine release is a possible cause of cardiac wall motion abnormality, as in our case.

Transient left ventricular dysfunction (tako-tsubo phenomenon): Findings and potential pathophysiological mechanisms

Tako-tsubo-like left ventricular dysfunction phenomenon (TTP) is characterized by transient left ventricular apical ballooning associated with symptoms, electrocardiographic changes and minimal cardiac enzyme release in the absence of coronary artery disease. Initially described in Japan, TTP occurs worldwide, predominantly in women and frequently after emotional or physical stress. Symptoms include anginal chest pain, dyspnea and syncope. Electrocardiographic ST elevations may be present only for several hours, and are followed by negative T waves that persist for months. Arterial hypertension is found in up to 76% of TTP patients, hyperlipidemia in up to 57% and diabetes mellitus in up to 12%. Potential pathophysiological mechanisms for TTP include catecholamine-induced myocardial stunning or hyperkinesis of the basal left ventricular segments, coronary vasospasm, plaque rupture, myocarditis and genetic factors. TTP patients should be monitored similarly to myocardial infarction patients because organ failure, cardiogenic shock, ventricular fibrillation or rupture may occur. Beta-blockers are indicated, whereas catecholamines and nitrates should be avoided. The long-term prognosis is unknown.