Coronary microvascular abnormality in the reversible systolic dysfunction observed after noncardiac disease

Takotsubo cardiomyopathy in the setting of severe hyponatremia and beer potomania: A case report

Takotsubo cardiomyopathy (TC), an acute cardiac event is often associated with acute emotional stress, usually in the setting of cardiovascular risk factors. This case report attempts to review one of the triggers of TC beer potomania-induce hyponatremia with imaging findings that shows the link between severe hyponatremia and TC.

Analysis of 9 Cases of Takotsubo Syndrome and an Analysis of the Clinical Characteristics of Takotsubo Syndrome From a Chinese Population

Objective: To summarize the clinical features, hematology and imaging features of Takotsubo syndrome. Methods: The hospitalization data of Takotsubo syndrome patients in the First Affiliated Hospital of Xinjiang Medical University from January 2015 to December 2020 were collected, and their clinical characteristics were summarized. Patient outcomes were clarified through follow-up visits, and relevant objective indicators were statistically analyzed before and after admission. The characteristics of TTS incidence in Chinese population were summarized by searching three (Wanfang, CNKI, China's VIP database) major databases in China (PRISMA). Results: A total of 9 patients were enrolled, including 6 females (66.7%). The mean age of onset was 46.4 years old, the median time from onset to treatment was 1 day. The main symptom of 8 cases (88.9%) was chest pain, 1 case had a main symptom of syncope, and 7 cases (77.8%) had mood fluctuations or mental stimulation as the main symptom of the disease. Paired T-tests were conducted on routine blood, biochemical, coagulation, myocardial markers, inflammatory indicators and objective indicators of ECG before and after admission. The study found that the counts of white blood cells and neutrophils were statistically significant (P < 0.05). Prolongation of the QT interval was observed in all 9 patients. After a mean follow-up of 24 ± 28 months, no adverse cardiovascular events or recurrence occurred. Conclusion: Takotsubo syndrome is a group of clinical syndromes with emotional or somatic stimulation and chest pain as the main symptoms, partly accompanied by an increase in white blood cells, neutrophilic granulocyte count, creatine kinase, and troponin and is characterized by a prolonged QT interval and no obvious coronary stenosis. The prognosis is generally good, with few serious complications.

Takotsubo cardiomyopathy in children

OBJECTIVE

To explore the epidemiology and outcomes of takotsubo cardiomyopathy in children.

METHODS

A retrospective analysis of the Healthcare Cost and Utilization 2012 and 2016 Kids' Inpatient Database was performed. Patients admitted with the diagnosis of takotsubo cardiomyopathy in the age group of 1 month-20 years were identified using International Classification of Diseases (ICD)-9 code 429.83 and ICD-10 code I51.81.

RESULTS

Among a total of 4,860,859 discharges, there were 153 with the diagnosis of takotsubo cardiomyopathy (3.1 per 100,000 discharges). Among patients with takotsubo cardiomyopathy, 55.0% were male, 62.4% were white, and 16.7% were black. Eighty-nine percent of patients were between 12 and 20 years. Psychiatric diagnosis was documented in 46% and substance use disorder in 36.2%. Sepsis was documented in 22.8% of patients. The median length of stay was 5 days (interquartile range: 2.7-15), and median total charges were $75,080 (interquartile range: 32,176-198,336). The overall mortality for takotsubo cardiomyopathy was 7%. On multivariable regression analysis, mortality was higher in the presence of anoxic injury (odds ratio = 34.42, 95% confidence interval: 4.85-320.11, p = 0.00).

CONCLUSIONS

Takotsubo cardiomyopathy is uncommon in children and carries a mortality rate of 7%. Most children with takotsubo cardiomyopathy are adolescent males, many of whom have psychiatric disorder or substance use disorder or both. Takotsubo cardiomyopathy should be considered in the differential diagnosis for patients who present with cardiac dysfunction and have underlying psychiatric disorders or drug abuse.

Takotsubo cardiomyopathy: FDG myocardial uptake pattern in fasting patients. Comparison of PET/CT, SPECT, and ECHO results

BACKGROUND

The aim of this study was to assess the accumulation pattern of 18F-FDG in fasting patients with takotsubo cardiomyopathy (TTC) and to correlate the results with perfusion scintigraphy and echocardiography.

METHODS

18 consecutive patients with TTC were identified by clinical symptoms, cardiac catheterization, and echocardiography. Coronary angiography (CA) and transthoracic echocardiography (TTE) were performed on the day of the onset of symptoms. An assessment of myocardial perfusion (99mTc-MIBI) and glucose metabolism (18F-FDG) was performed within 18 days.

RESULTS

SPECT showed no regional perfusion abnormalities in 10/18 patients, and a mild perfusion defect was found in 8/18 patients. Perfusion abnormalities were limited to apical and para-apical regions. In 8/18 cases, there was an increased selective apical 18F-FDG accumulation. In 10/18 cases, in spite of the fastened 18F-FDG protocol, slightly inhomogeneous 18F-FDG uptake was present in the entire myocardium: with relatively reduced uptake of 18F-FDG in the apical region and LV mid-segments.

CONCLUSION

This study demonstrated the heterogeneous nature of myocardial 18F-FDG accumulation in patients with TTC. Selective, preferential apical 18F-FDG uptake in almost half of the patients confirms an existing disorder of glucose metabolism, similar to that observed in stunned or hibernated myocardium.

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.

Cardiac Dysfunction After Neurologic Injury: What Do We Know and Where Are We Going?

Recent literature has implicated severe neurologic injuries, such as aneurysmal subarachnoid hemorrhage, as a cause of cardiac dysfunction, impaired hemodynamic function, and poor outcomes. Mechanistic links between the brain and the heart have been explored in detail over the past several decades, and catecholamine excess, neuroendocrine dysfunction, and unchecked inflammation all likely contribute to the pathophysiologic process. Although cardiac dysfunction has also been described in other disease paradigms, including septic shock and thermal injury, there is likely a common underlying pathophysiology. In this review, we will examine the pathophysiology of cardiac dysfunction after neurologic injury, discuss the evidence surrounding cardiac dysfunction after different neurologic injuries, and suggest future research goals to gain knowledge and improve outcomes in this patient population.

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.

Fractional flow reserve: physiological basis, advantages and limitations, and potential gender differences

Fractional flow reserve (FFR) is a physiological index of the severity of a stenosis in an epicardial coronary artery, based on the pressure differential across the stenosis. Clinicians are increasingly relying on this method because it is independent of baseline flow, relatively simple, and cost effective. The accurate measurement of FFR is predicated on maximal hyperemia being achieved by pharmacological dilation of the downstream resistance vessels (arterioles). When the stenosis causes FFR to be impaired by > 20%, it is considered to be significant and to justify revascularization. A diminished hyperemic response due to microvascular dysfunction can lead to a false normal FFR value, and a misguided clinical decision. The blunted vasodilation could be the result of defects in the signaling pathways modulated (activated or inhibited) by the drug. This might involve a downregulation or reduced number of vascular receptors, endothelial impairment, or an increased activity of an opposing vasoconstricting mechanism, such as the coronary sympathetic nerves or endothelin. There are data to suggest that microvascular dysfunction is more prevalent in post-menopausal women, perhaps due to reduced estrogen levels. The current review discusses the historical background and physiological basis for FFR, its advantages and limitations, and the phenomenon of microvascular dysfunction and its impact on FFR measurements. The question of whether it is warranted to apply gender-specific guidelines in interpreting FFR measurements is addressed.

Clinical characteristics of myocardial stunning in acute stroke

Neurogenic stunned myocardium (NSM) after subarachnoid hemorrhage (SAH) is well known, but there is a paucity of data regarding its occurrence following acute stroke. The aim of this study is to investigate the clinical characteristics of NSM in acute non-hemorrhagic stroke. We performed an electronic literature search with Medline and Google Scholar for English-language articles using the terms "ischemic stroke" along with "stunned myocardium" or "Takotsubo cardiomyopathy". The search resulted in seven case reports/series, but no prospective studies. The mean age of patients with myocardial stunning following ischemic stroke was 72.5 years and 77% of these patients were females. Insular cortex was involved in 38.4% of cases. Mean National Institutes of Health Stroke Scale (NIHSS) score at admission was 12.6 and mean NIHSS at discharge was 10.8. T-wave inversions and ST-segment elevations were noted in 84.6% and 69.2% of patients, respectively. Mean troponin elevation was 0.64 mcg/dL and mean left ventricular ejection fraction (LVEF) was 34.4%. In terms of outcomes, 84.6% of patients had significant improvement in LVEF, mostly within 4 weeks of onset of symptoms. To summarize, NSM was more common in females, with favorable prognosis. Less than half the patients with NSM following stroke had insular involvement. The mean troponin level in NSM after stroke was only half of that seen in SAH. While the lack of prospective studies on NSM in stroke patients precludes drawing further conclusions, more studies are warranted to investigate the risk factors for NSM and the effect on stroke outcomes.

Acute cardiac sympathetic disruption in the pathogenesis of the takotsubo syndrome: a systematic review of the literature to date

Takotsubo syndrome (TS), also known as broken heart syndrome and neurogenic stunned myocardium, is an acute cardiac disease entity characterized by a clinical picture mimicking that of an acute coronary syndrome. The pathogenesis of TS has not been established yet. Among the most often debated pathologic mechanisms of TS are as follows: first, multi-vessel coronary spasm; second, myocardial microvascular dysfunction; third, aborted myocardial infarction caused by transient thrombotic occlusion of a long wrap-around left anterior descending artery; fourth, left ventricular outflow tract obstruction; fifth, blood-borne catecholamine cardiac toxicity; and sixth, cardiac sympathetic disruption and norepinephrine seethe and spillover. The aim of this review is to provide a thorough analysis of the literature data coming mainly from the neurological literature and dealing with the pathogenesis of TS. Substantial evidence challenging the first five hypotheses and arguing in favor of the hypothesis that acute cardiac sympathetic eruption and norepinephrine seethe and spillover is causing TS in predisposed patients is presented.

Termination of dobutamine infusion causes transient rebound left heart diastolic dysfunction in healthy elderly women but not in men: a cardiac magnetic resonance study

Men and women are known to react differently to stress. Thus, stress cardiomyopathy almost solely strikes women. Stress cardiomyopathy is suggested to relate to sex differences in catecholamine reaction. Left heart function during dobutamine stress is well described, but sex-specific inotropic and lusitropic response to abrupt termination of dobutamine stress is not. We aimed to investigate sex differences in left ventricular (LV) and atrial (LA) function during and after dobutamine stress. We enrolled 20 healthy elderly subjects (60–70 yr, 10 females) and measured their LV and LA volumes throughout the cardiac cycle by cardiac magnetic resonance imaging at rest, during dobutamine stress (15 μg·kg−1·min−1), 15 min after termination (T15), and 30 min after termination (T30) of dobutamine stress. We calculated LV ejection fractions, LV stroke volumes, LV peak filling rates, and LA passive, active, and conduit volumes. Sex differences were not observed at rest or during dobutamine stress. Compared with prestress values, at T15 a rebound decrease in LV peak filling rate was observed in women (−22 ± 3%, P < 0.001) but not in men. This was reflected in reduced LA passive emptying volume (−40 ± 3%, P < 0.001) and a corresponding increase in LA active emptying volume (36 ± 2%, P < 0.001). At T30 there were no differences between the sexes. We conclude that dobutamine causes greater stress to the female heart. This is revealed after termination of dobutamine stress where the left heart recovers in men, whereas women experience rebound LV stiffening with reduced diastolic relaxation. This is the first report of a sex-specific transient rebound phenomenon in cardiovascular response to catecholamines.

Takotsubo cardiomyopathy after treatment of pulmonary arterial hypertension

Pulmonary arterial hypertension is a fatal disease. Intravenous prostanoids are often utilized for long-term management of patients. The therapy requires a significant commitment and change in lifestyle for both the patient and family. Takotsubo cardiomyopathy, transient apical ballooning syndrome, has been reported in association with emotional and physical stress. This case report describes a patient with pulmonary arterial hypertension who developed Takotsubo cardiomyopathy after treatment initiation with intravenous treprostinil. Over time, the syndrome resolved and the patient had return of normal left ventricular function. Takotsubo cardiomyopathy should be recognized as a potential, rare complication of therapy initiation due to the severity of the illness and the emotional stress of the disease.

Insights into the pathogenesis of takotsubo syndrome, which with persuasive reasons should be regarded as an acute cardiac sympathetic disease entity

The pathogenesis of takotsubo syndrome (TS) has not been established yet. The literature data dealing with the pathogenesis of TS are abundant but scattered among different medical specialities. Subarachnoid hemorrhage and other acute intracranial diseases and injuries are among the important and currently well-recognized trigger factors for TS. In both induced and spontaneous subarachnoid hemorrhages, signs suggestive of increased cardiac sympathetic overactivity have been documented. Surgical and pharmacological sympathectomy has shown to have protective cardiac effects in both animal and human studies. Increase in local release of norepinephrine from the heart of patients with TS has been measured. Signs of both cardiac sympathetic denervation and myocardial lesions adjacent to the cardiac nerve terminals have been seen. Furthermore, the systematized and typically circumferential pattern of ventricular wall motion abnormality is incongruent with the coronary artery supply region and appears most likely to follow the cardiac sympathetic nerve distribution. In conclusion, compelling literature data support the hypothesis that acute cardiac sympathetic disruption and norepinephrine seethe and spillover is causing TS in predisposed patients. TS is most probably an acute cardiac sympathetic disease entity causing myocardial stunning in which takotsubo is one among other cardiac image study findings.

The impact of stressor patterns on clinical features in patients with tako-tsubo cardiomyopathy: experiences of two tertiary cardiovascular centers

BACKGROUND

Tako-tsubo cardiomyopathy (TTC) is typically triggered by an acute emotional or physical stress event. The aim of this study was to investigate the impact of stressor patterns on clinical features, laboratory parameters, and electrocardiographic and echocardiographic findings in patients with TTC.

HYPOTHESIS

Clinical features are different according to stressor patterns.

METHODS

Of 137 patients enrolled from the TTC registry database, 14 patients had emotional triggers (E group), 96 had physical triggers (P group), and 27 had no triggers (N group).

RESULTS

Most clinical presentations and in-hospital courses were similar among the groups. However, the E group had a higher prevalence of chest pain (P = 0.006) and palpitation (P = 0.006), whereas the P group had a higher prevalence of cardiogenic shock (P = 0.040), than other groups. The P group had a significantly higher heart rate (P = 0.001); higher high-sensitivity C-reactive protein (P = 0.006), creatine kinase MB fraction (P = 0.045), and N terminal-probrain natriuretic peptide (P = 0.036) levels; higher left ventricular end-diastolic pressure (P = 0.019) and left ventricular end-systolic diameter (P = 0.002); but lower left ventricular ejection fraction (P = 0.018). The E group had lesser prevalence of apical ballooning pattern (P = 0.038) than other groups. The P group required more frequent use of inotropics (P = 0.041) and diuretics (P = 0.047) and had significantly longer intensive care unit (P = 0.014) and in-hospital stays (P = 0.001).

CONCLUSIONS

The clinical features of TTC are different according to preceding stressor patterns. The TTC group with preceding physical stressors was less likely to have preserved cardiovascular reserve and more likely to require hemodynamic support than other groups. The overall prognosis of TTC is excellent, regardless of triggering stressors.

The clinical features and emotional stressors in korean patients with tako-tsubo cardiomyopathy

Background. Tako-tsubo cardiomyopathy (TTC) is typically triggered by an acute emotional or physical stress events. Aim of this study was to investigate the impact of emotional stressors on clinical features, laboratory parameters, electrocardiographic and echocardiographic findings in patients with TTC. Methods. Of 103 patients enrolled from the TTC registry database, fifteen patients had emotional triggers (E group), and 88 patients had physical triggers or no triggers (other group). Results. Most clinical presentations and in-hospital courses were similar between the groups. However, E group had higher prevalence of chest pain (87 versus 42 %, P = 0.001), palpitation (27 versus 6%, P = 0.008), whereas other group had higher prevalence of cardiogenic shock (35 versus 7%, P = 0.027). E group had significantly higher corrected QT intervals (median, 477.5 versus 438 ms, P = 0.001), and left ventricular ejection fraction (LVEF) (mean, 45.7 versus 39.6%, P = 0.001), but lower hs-CRP (median, 0.1 versus 3.3 mg/L, P = 0.001), CK-MB (median, 5.5 versus 11.9 ng/mL, P = 0.047), troponin-I (median, 1.0 versus 3.2 ng/mL, P = 0.011), and NT-proBNP levels (median, 2145 versus 4939 pg/mL, P = 0.020). Other group required more frequent hemodynamic support and had significantly longer intensive care unit (median, 3 versus 1 days, P = 0.005) and in-hospital (median, 17 versus 3 days, P = 0.001) durations. Conclusion. The clinical features of TTC are different between groups with and without preceding emotional stressors. The TTC group with preceding emotional stressors was more likely to have preserved cardiovascular reserve and lesser likely to require hemodynamic support than other group although the entire prognosis of TTC is excellent regardless of triggering stressors.

Takotsubo-like myocardial dysfunction accompanied with cerebellar hemorrhage

We report a 71-year-old woman with takotsubo-like myocardial dysfunction accompanied with cerebellar hemorrhage. On admission time, although she was unconscious by cerebellar hemorrhage, no obvious heart failure and serological disorder were observed. Three days later, operation for extraventricular drainage was performed. However, conscious level did not change. Four days after admission, the change of electrocardiogram wave pattern and the decrement of heart wall motion were detected. These findings revealed takotsubo-like myocardial dysfunction had occurred. Physical stresses by cerebellar hemorrhage and cranial operation might cause cardiac disorder. This is a remarkable case of takotsubo-like myocardial dysfunction, which is brought about cerebellar hemorrhage against subarachnoid hemorrhage.

Recurrence of Takotsubo cardiomyopathy with coronary slow flow phenomenon

This report presents the case of a 54-year-old female with Takotsubo cardiomyopathy that recurred 12 years after the first episode. The coronary angiography at the first admission revealed ergonovine-induced coronary vasoconstriction in the left coronary artery, and recurrence recurred after the interruption of vasodilator therapy to prevent vasospasm. In addition, the coronary angiography both in the first and second event demonstrated coronary slow flow phenomenon, which improved after the intracoronary administration of nicorandil. These findings indicate that coronary microvascular constriction plays an important role in the pathophysiology of Takotsubo cardiomyopathy.

High blood pressure, ventricular tachycardia and transient left ventricular dysfunction: do not forget pheocromocytoma

Pheochromocytoma is a neuroendocrine tumour of the adrenal gland that secretes an excessive amount of catecholamines, leading to a rapid rise and fall in blood pressure, headache, sweating and palpitations. The clinical scenario of pheochromocytoma, however, may be extremely variable and may include atypical cardiovascular manifestations, eventually leading to delays or mistakes in diagnosis. This issue is crucial since a missed diagnosis of pheochromocytoma may imply fatal consequences. This article reports a case of pheochromocytoma presenting with quite atypical cardiovascular manifestations such as transient left ventricular dysfunction and ventricular tachycardia. The pathophysiological determinants underlying uncommon clinical presentations of pheochromocytoma are also discussed. Received for publication 19 May 2011; accepted for publication 10 June 2011.

An unusual electrocardiographic manifestation of Takotsubo cardiomyopathy

An elderly Malay lady presented with lethargy and 2-day history of chest pain. Her electrocardiogram showed diffuse concave ST-segment elevation with depressed PR segments. Coronary angiogram was normal. The left ventriculogram demonstrated apical akinesis with hyperdynamic contraction of the basal segments consistent with feature of Takotsubo cardiomyopathy. This case highlights an uncommon electrocardiogram presentation of Takotsubo cardiomyopathy.

Takotsubo Cardiomyopathy: A Cardiac Syndrome Mimicking Acute Myocardial Infarction in a Liver Transplant Recipient

Takotsubo cardiomyopathy (TTC) is a rare clinical syndrome defined as a profound but reversible left ventricular dysfunction in the absence of coronary artery disease. We describe the clinical features and management of TC manifesting in the postoperative period in a patient undergoing liver transplantation. Two days after surgery, the patient developed clinical features of acute myocardial infarction. Ecochardiography revealed hypokinesis of the left ventricle. Coronary angiography revealed normal arteries without any stenosis or obstruction. The patient required vasopressor and inotropic support. The placement of intra-aortic balloon pump had a beneficial effect on the management of heart failure. The patient had a complete recovery of cardiac function 40 days after surgery. TC is a possible occurrence after liver transplant. Awareness of this condition is essential as early diagnosis and prompt management can save the patient’s life.

Takotsubo cardiomyopathy in acute coronary syndrome; clinical features and contribution of cardiac magnetic resonance during the acute and convalescent phase

OBJECTIVES

Takotsubo cardiomyopathy (TTC) is a diagnostic entity that is increasingly being recognized. Data from cardiac magnetic resonance (CMR) imaging and its impact on differential diagnosis are limited.

METHODS AND RESULTS

After 26 months, coronary angiography revealed normal coronary arteries and left ventriculography and/or echocardiography left ventricular dysfunction with apical ballooning in 20 patients with acute coronary syndrome (ACS). Four patients were excluded from CMR and in three patients an alternative diagnosis was revealed. Thirteen patients (all female; 60 ± 8 years) with TTC underwent a multisequential CMR, in which all showed myocardial oedema with an elevated T2 ratio in the apical region (2.4 ± 0.4; p < 0.001 vs. healthy controls), and five patients an elevated global relative enhancement (gRE; 3.7 ± 1.4; p < 0.05 vs. healthy controls). No late gadolinium enhancement (LGE) was detected on CMR. Follow-up after 132 ± 33 days showed a normalized left ventricular ejection fraction, myocardial mass, T2 ratio, and gRE in all patients.

CONCLUSIONS

TTC is a small but definite group among patients with ACS and normal coronary arteries. CMR allows differentiating TTC from other causes such as myocarditis and cardiomyopathies, as well as to identify the transient increase of myocardial mass and resolution of myocardial oedema as the systolic dysfunction improves. Therefore, CMR might add valuable information for the differential diagnoses and therapeutic decision-making in patients with suspected TTC.

Current advances in the understanding of coronary vasospasm

Recent years have witnessed progress in our understanding of coronary vasospasm (CVS). It is evident that this is not only an East Asian but also a global disease associated with significant symptoms and possible lethal sequelae for afflicted individuals. A correct diagnosis depends on the understanding of pathogenesis and symptomatology of CVS. With the correct diagnosis, we can manage CVS patients effectively and promptly, providing optimal patient safety. Advances in our understanding of interactions between inflammation, endothelium, and smooth muscle cells have led to substantial progress in understanding the pathogenesis of symptoms in CVS and have provided some insights into the basic etiology of this disorder in some patient subpopulations. We look forward to a time when therapy will address pathophysiology and perhaps, even the primary etiology.

Microvascular function in Takotsubo cardiomyopathy with contrast echocardiography: prospective evaluation and review of literature

BACKGROUND

Takotsubo cardiomyopathy (TC) mimics ST-elevation myocardial infarction without substantial angiographic stenosis. Coronary microvascular dysfunction has been proposed as a possible mechanism in TC. The aim of this study was to evaluate microvascular function in TC using real-time myocardial contrast echocardiography (MCE).

METHODS

Real-time MCE was performed within 24 hours of coronary angiographic diagnosis of TC. Myocardial perfusion was evaluated through qualitative and quantitative myocardial contrast echocardiographic analyses comparing normal segments with segments with dysfunctional wall motion (WM).

RESULTS

From January 2007 to January 2008, 11 patients received diagnoses of TC. Of these patients, 9 were prospectively enrolled (mean age, 70.9 +/- 17.5 years; 8 women). Qualitative and quantitative myocardial contrast echocardiographic analyses were feasible in 87% and 81% of segments. Overall, concordance between qualitative MCE and WM for normal versus abnormal analysis was observed in 71% of segments (kappa = 0.442, SE = 0.08). Significantly lower myocardial blood flow velocity (beta) and lower myocardial blood flow (Abeta) were detected in segments with dysfunctional WM compared with those with normal WM (beta = 0.55 +/- 0.39 vs 0.90 +/- 0.77, P = .009; Abeta = 5.31 +/- 3.92 vs 12.38 +/- 13.47, P = .002). In the discordant segments between qualitative MCE and WM, the quantitative perfusion parameters beta and Abeta were significantly lower in segments with dysfunctional WM compared with those with normal WM (beta = 0.22 +/- 0.20 vs 1.79 +/- 0.57, P = .01; Abeta = 1.90 +/- 1.1 vs 24.29 +/- 19.9, P = .02). Recovery of WM abnormalities was detected in all patients during follow-up echocardiography (mean, 60.3 +/- 66.0 days). No contrast-related side effects were reported. During mean follow-up of 5.9 +/- 4.6 months, there were no cardiac events, but 1 noncardiac death (from lung cancer) occurred.

CONCLUSION

TC is associated with abnormal myocardial perfusion detected with qualitative and quantitative MCE, indicative of microvascular dysfunction.

Acute ischemic cardiomyopathy after extreme emotional stress in a child

Ischemic cardiomyopathy is rare in children. It is usually caused by congenital anomalies of coronary arteries, coronary anomalies after coronary artery transfer, or Kawasaki disease. In recent years, a new cardiac syndrome-named "Tako-Tsubo cardiomyopathy" for the particular shape of the end systolic ventricle-has been described in adults. In the absence of coronary artery obstruction, it mimics acute myocardial infarction with chest pain and typical electrocardiography changes. Emotional or physical stress usually precedes this cardiomyopathy. At present, this entity has only been described in adults, with a strong predominance in postmenopausal women. We report a case of acute ischemic cardiomyopathy after extreme stress in a child that may share the same pathophysiology.

Inflammation in takotsubo cardiomyopathy: insights from cardiovascular magnetic resonance imaging

OBJECTIVE

Takotsubo cardiomyopathy (TTC) is an increasingly recognised acute cardiac syndrome, whose underlying pathophysiological mechanisms remain unknown. Inflammation might play a role as this has been shown in endomyocardial biopsies. The aim of this study was to assess inflammatory parameters in patients with TTC using a comprehensive cardiovascular magnetic resonance imaging (CMR) approach.

METHODS

Thirty-seven patients with the suspected diagnosis of TTC underwent CMR. T2-weighted imaging to calculate the oedema ratio, T1-weighted imaging before and after contrast agent administration to calculate the global relative enhancement (gRE), and late gadolinium enhancement (LGE) imaging were performed.

RESULTS

In 11 patients CMR revealed the diagnosis of myocardial infarction (n = 7; 19%) or myocarditis (n = 4; 11%) with typical patterns of LGE. In all other patients (n = 26; 70%), no LGE was detected consistent with the diagnosis of TTC. Of these, in 16 patients (62%) both inflammatory markers (oedema ratio and gRE) were elevated with concomitant pericardial effusion, indicating acute inflammation. Follow-up CMR after 3 months showed complete normalisation of left ventricular function and inflammatory parameters in the absence of LGE and pericardial effusion.

CONCLUSION

This CMR study provides further insights into the pathophysiological mechanisms in TTC, supporting the contribution of an inflammatory process in the acute setting.

[Takotsubo cardiomyopathy and cerebral infarction]

Takotsubo cardiomyopathy is reversible left ventricular dysfunction and apical ballooning resembling acute myocardial infarction. Although Takotsubo cardiomyopathy is a well-known complication of subarachnoid hemorrhage, it is rare in patients with acute cerebral infarction. We reviewed the findings of thirty previously published cases with both Takotsubo cardiomyopathy and cerebral infarction. These cases were divided into three groups (A-C) according to etiology. A; Dysfunction of central autonomic network associated with cerebral infarction caused Takotsubo cardiomyopathy, B; Left ventricular thrombus associated with Takotsubo cardiomyopathy caused cardioembolic stroke. C; The unknown relation of cause and effect. Most patient were elderly women in all groups. Group A mostly included the territory of middle cerebral artery or basilar artery as the infarcts area. The cardiomyopathy in group A often occurred within 24 hours after stroke onset and was commonly asymptomatic. On the other hand, the cardiomyopathy in group B often was commonly symptomatic. But some cases with mild cardiac symptom in group B was diagnosed by embolic event. Takotsubo cardiomyopathy can notably be both the cause and effect of stroke. The 'chicken or egg' issue regarding stroke etiology in group C is sometimes not simple to resolve.

Management of Tako-tsubo syndrome

INTRODUCTION

This manuscript reviews the current evidence for proposed pathophysiological mechanisms of Tako-tsubo syndrome and its management.

DISCUSSION

The Tako-tsubo syndrome is defined by the presence of transient left ventricular apical ballooning after an acute coronary syndrome in patients with angiographically normal coronary arteries. Intriguingly, only the apex is affected and compensatory basal hypercontractility is seen. Several mechanisms have been offered as explanations for the characteristic clinical presentation and echocardiographic appearance of this syndrome.

CONCLUSION

Tako-tsubo syndrome encompasses heterogeneous patient populations and it is likely that different pathogenic mechanisms may operate in different patients. Treatment of the condition is at present empirical and aimed at preserving ventricular function.

Importance of inflammation and neurohumoral activation in Takotsubo cardiomyopathy

BACKGROUND

To gain more insight into the involvement of inflammatory response and neurohumoral activation in Takotsubo cardiomyopathy (TTC), we investigated C-reactive protein (CRP), leukocytes, plasma catecholamines levels, iodine 123 meta-iodobenzylguanidine (123I-mIBG) myocardial uptake, myocardial perfusion (thallium 201 [201Tl] or technetium [Tc] 99m-tetrofosmin myocardial single photon emission computed tomography [SPECT]), and metabolism (fluorine 18-fluorodeoxyglucose positron emission tomography).

METHODS AND RESULTS

Inflammatory status and brain natriuretic peptide (BNP) levels in 17 patients with TTC were compared with 14 age-matched patients. In TTC, elevated levels of CRP were evidenced on admission, reaching a peak in the following days (P < .01). CRP levels were correlated to baseline left ventricular ejection fraction (LVEF) and BNP levels (P < .05). Leukocytes were correlated to BNP and noradrenaline levels. Myocardial 123I-mIBG SPECT showed a reduced activity in the midventricle and apex corresponding to 35% +/- 23% of the total myocardial mass, partially reversible at follow-up. An identical pattern was retrieved when assessing myocardial glucose metabolism. At rest, no relevant abnormalities of myocardial perfusion could be evidenced at the subacute phase.

CONCLUSION

Inflammatory status in TTC was related to LVEF impairment and to the extent of neurohormonal activation. The hypothesis of a catecholamine-induced myocardial "stunning" is emphasized by the evidence of a reduced 123I-mIBG myocardial activity, impairment of myocardial glucose metabolism, and wall motion kinetic after the same temporospatial distribution.

Major depression as a potential trigger for Tako Tsubo cardiomyopathy

Tako-Tsubo cardiomyopathy (TTC) is characterized by the sudden onset of severe left ventricular contractile dysfunction following profound emotional or physical stress. The underlying pathomechanism still remains to be elucidated. In this case we present a, to date, unique case of a female patient suffering from an episode of major depression who shows characteristic features of TTC.

Sympathoadrenergic overstimulation in Tako-Tsubo cardiomyopathy triggered by physical and emotional stress

Tako-Tsubo cardiomyopathy (TTC) which is usually precipitated by profound emotional stress has been widely reported in the past. Recently, several co-morbidities have been found to be associated with this new cardiac entity. In this case we report from a female patient suffering from both, physical and emotional stress. After a persistent episode of severe abdominal pain due to acute cholecystitis and recurrent events of emotional stress, characteristic features of TTC could be documented. Histopathological analysis documented characteristic structural alterations including contraction band necrosis. Thus, this case confirms the hypothesis of an overstimulated sympthatoadrenergic system in TTC resulting from both, severe physical and emotional stress.

Near-drowning syndrome: a possible trigger of tako-tsubo cardiomyopathy

We report a case of transient tako-tsubo cardiomyopathy characterized by an unusual trigger in a woman victim of near-drowning syndrome. After 24 h, electrocardiogram changes and a typical echocardiographic pattern of apical ballooning with a mild increase of serum troponin level induced the suspicion of tako-tsubo cardiomyopathy despite the absence of chest pain. Left ventriculography confirmed the apical ballooning, and coronary angiography revealed normal coronary arteries. Electrocardiogram changes and apical contraction abnormalities were reversed within 1 month. In conclusion, we hypothesize that hypoxemia related to near-drowning syndrome could have induced transient myocardial dysfunction mediated by a sympathetic nerve activation.

Cardiogenic shock secondary to Tako-tsubo syndrome after debridement of malignant endobronchial obstruction

Transient left ventricular (LV) dysfunction syndrome, or Tako-tsubo syndrome, occurs following intense emotional or physical stress and simulates the clinical presentation of an acute myocardial infarction. We report a case of a 77-year-old man with esophageal adenocarcinoma with local invasion of the central airways who underwent rigid bronchoscopy for tumor debridement followed by placement of a stent. Postoperatively, cardiogenic shock developed and echocardiography revealed akinesis of the LV apex with an ejection fraction (EF) of 15%. Emergent coronary angiography revealed no significant coronary artery disease. The patient required intraaortic balloon counterpulsation and pressors. Seventy-two hours later, repeat echocardiography showed an EF of 45% with improvement in apical function, and the patient was discharged home in stable condition shortly thereafter. A 5-month follow-up echocardiogram revealed an EF > 55%, and the patient enjoyed an excellent performance status.

Reversible impairment of coronary flow reserve in takotsubo cardiomyopathy: a myocardial PET study

BACKGROUND

The precise etiology of takotsubo cardiomyopathy remains unclear. The study of myocardial blood flow (MBF) and coronary flow reserve (CFR) by use of positron emission tomography might help in understanding this syndrome.

METHODS AND RESULTS

Three postmenopausal women underwent adenosine/rest perfusion with nitrogen 13 ammonia and metabolism with fluorine 18 fluorodeoxyglucose positron emission tomography, coronary angiography, cardiac magnetic resonance, and echocardiography in the acute phase of takotsubo cardiomyopathy and at 3 months' follow-up, after normalization of left ventricular function. PET study was performed in 2 parts: the perfusion analysis with nitrogen ammonia and the metabolism of the heart using FDG. MBF and CFR were analyzed quantitatively in the acute phase and at follow-up. The images highlighted the impairment of tissue metabolism in the dysfunctioning left ventricular segments in the acute phase, mainly in the apical segments and progressively less in the medium segments. At the same time, a clear inverse metabolic/perfusion mismatch emerged, which normalized 3 months later. The quantitative analysis of MBF showed a reduction in the acute phase in apical segments in comparison to basal segments without differences between midventricular and basal segments. In the acute phase CFR proved to be reduced in apical versus basal segments. CFR impairment of apical segments recovered completely after 3 months.

CONCLUSION

The acute phase of takotsubo cardiomyopathy is characterized by an inverse perfusion/metabolism mismatch with a reduction in CFR in the apical segments. However, the impairment of CFR and the reduction of metabolism in the apical segments recovered completely after 3 months.

Reversible impairment of coronary flow reserve in takotsubo cardiomyopathy: a myocardial PET study

BACKGROUND

The precise etiology of takotsubo cardiomyopathy remains unclear. The study of myocardial blood flow (MBF) and coronary flow reserve (CFR) by use of positron emission tomography might help in understanding this syndrome.

METHODS AND RESULTS

Three postmenopausal women underwent adenosine/rest perfusion with nitrogen 13 ammonia and metabolism with fluorine 18 fluorodeoxyglucose positron emission tomography, coronary angiography, cardiac magnetic resonance, and echocardiography in the acute phase of takotsubo cardiomyopathy and at 3 months' follow-up, after normalization of left ventricular function. PET study was performed in 2 parts: the perfusion analysis with nitrogen ammonia and the metabolism of the heart using FDG. MBF and CFR were analyzed quantitatively in the acute phase and at follow-up. The images highlighted the impairment of tissue metabolism in the dysfunctioning left ventricular segments in the acute phase, mainly in the apical segments and progressively less in the medium segments. At the same time, a clear inverse metabolic/perfusion mismatch emerged, which normalized 3 months later. The quantitative analysis of MBF showed a reduction in the acute phase in apical segments in comparison to basal segments without differences between midventricular and basal segments. In the acute phase CFR proved to be reduced in apical versus basal segments. CFR impairment of apical segments recovered completely after 3 months.

CONCLUSION

The acute phase of takotsubo cardiomyopathy is characterized by an inverse perfusion/metabolism mismatch with a reduction in CFR in the apical segments. However, the impairment of CFR and the reduction of metabolism in the apical segments recovered completely after 3 months.

Left ventricular apical ballooning syndrome: prevalence, clinical characteristics and pathogenetic mechanisms in a European population

BACKGROUND

Left ventricular apical ballooning syndrome (LVABS) is a cardiac syndrome mimicking acute myocardial infarction, whose prevalence in western populations and pathogenesis are not yet well defined. The aim of the study was to assess its prevalence, clinical characteristics and pathophysiological mechanisms in a European population of myocardial infarction patients.

METHODS

Of a series of 1457 patients with acute myocardial infarction 18 fulfilled the diagnostic criteria for LVABS. To evaluate the pathogenetic mechanisms we studied coronary blood flow with TIMI flow grade and corrected TIMI frame count (CTFC) in all patients and performed provocative testing with ergonovine and dobutamine echocardiography in 14.

RESULTS

All patients were women aged 72+/-9 years. A triggering event was identifiable in 39% of cases. LV ejection fraction in the acute phase was 46+/-5%. No deaths or major complications occurred during hospitalization. Response to ergonovine was negative in all 14 patients and dobutamine induced a dynamic LV obstruction in 4/14 (28%). Mean CTFC was abnormally prolonged in all 3 major coronary arteries and 16/18 patients (89%) had an abnormal CTFC in >/=1 coronary vessel. No cardiac deaths occurred during follow-up and 1 patient only had a recurrence.

CONCLUSIONS

The prevalence of LVABS is 1.2% among all patients with acute myocardial infarction, but rises to 4.9% in women. Short- and long-term prognosis is good. Abnormal CTFC suggests the presence of a coronary microvascular dysfunction, while dynamic LV obstruction can contribute to the development of LVABS in a minority of patients.

Tako-Tsubo-Like Syndrome with Atypical Clinical Presentation: Case Report and Literature Review

A 78-year-old woman presented herself at emergency for the appearance of severe dyspnea. An electrocardiogram showed signs of inferior and anterior necrosis, and laboratory tests showed a small increase of myocardial cytonecrosis enzymes. An echocardiogram detected a reduction of global systolic function (ejection fraction [EF] approximately 40%) as well as akinesia of the apex, interventricular septum middle segments, and anterior and anterolateral walls, with basal segments showing compensatory hyperkinesia. The coronarography showed a coronary tree substantially free from significant lesions. The patient was transferred to the cardiology unit of our hospital. Based on the contained increase of the cardiac enzymes, the absence of coronary lesions, and the presence of typical echocardiography alterations, we suspected a Tako-tsubo-like syndrome. On deeper anamnestic investigation, an event of strong emotional stress emerged preceding the hospital admission that confirmed the pathology, even though it is atypical to see clinical presentation a long time after a stressful event.

Semi-automated analysis of coronary flow Doppler images: validation with manual tracings

Coronary flow velocity reserve (CFVR) is conventionally obtained by manual tracings of Doppler profiles, as ratio of stress vs baseline diastolic peak velocity. When <1.9, this parameter evidences reduced coronary flow and possible microcirculatory disease. Our goals were: 1) to develop a novel technique for semi-automated detection of Doppler flow velocity profile, allowing the automated computation of CFVR and other parameters; 2) to validate this technique in comparison with conventional measurements obtained by manual tracing; 3) to test for differences between normal (N) subjects and patients with rheumatoid arthritis (RA). Linear correlation and Bland-Altman analyses showed that the proposed method was highly accurate and repeatable compared to the manual measurements. Comparison between N and RA groups evidenced significant differences in some of the automated parameters.

Stress cardiomyopathy: aetiology and management

Stress cardiomyopathy is a condition caused by intense emotional or physical stress leading to rapid and severe reversible cardiac dysfunction. It mimics myocardial infarction with changes in the electrocardiogram and echocardiogram, but without any obstructive coronary artery disease. Due to the awareness created by the media and internet, every patient is aware that they should seek help immediately for chest pain. Therefore physicians should be aware of this new condition and how to diagnose and treat it, even though the causal mechanisms are not yet fully understood.