Hepatic Artery Thrombosis and Takotsubo Syndrome After Liver Transplantation - Which Came First?

A Comprehensive Review on Alcohol Abuse Disorder Fatality, from Alcohol Binges to Alcoholic Cardiomyopathy

Frequent and excessive consumption of alcohol, be it episodic or sustained misuse, ranks among the top causes of mortality globally. This comprehensive analysis seeks to elucidate how alcohol misuse precipitates death, with a particular focus on associated cardiac anomalies. Notably, the phenomenon of "Holiday Heart Syndrome", linked to binge drinking, is recognized for inducing potentially fatal cardiac arrhythmias. Moreover, persistent alcohol consumption is implicated in the development of alcoholic cardiomyopathy, a condition that underlies heart failure and arrhythmic disturbances of the heart. Additionally, individuals undergoing withdrawal from alcohol frequently exhibit disruptions in normal heart rhythm, posing a risk of death. This review further delves into additional alcohol-related mortality factors, including the heightened likelihood of hypertension, cerebrovascular accidents (strokes), and the connection between excessive alcohol use and Takotsubo syndrome.

Takotsubo cardiomyopathy after solid organ transplantation: a scoping review

Takotsubo syndrome (TTS) is a stress-induced cardiomyopathy that causes temporary left ventricular wall motion abnormalities and abrupt reversible heart failure. The incidence of perioperative TTS is proportional to the severity of surgical trauma, the duration of the procedure, and the degree of apparent sympathetic activity. A growing number of articles have discussed TTS after a solid organ transplant (SOT), which is one of the circumstances in which physical and emotional stress are at their highest levels. The majority of published cases involved patients who had received an orthotopic liver transplant (OLT). TTS occurred in 0.3-1.7% of liver transplant recipients, but a limited number of cases of TTS in patients who had received kidney, heart, or lung transplants have also been documented. In this study, we analyzed the TTS instances that developed after SOT, highlighting the symptoms and causes as well as the various treatment approaches that were applied. Most TTS cases following OLT and kidney transplant cases occurred in the first week of the surgery. However, the majority of cases occurred years after heart transplantation. Dizziness, dyspnoea, and chest discomfort are the most typical symptoms. Patients may also experience syncope and generalized weakness. In spite of this, the symptoms differ depending on the transplanted organ. Dyspnoea is a common symptom after lung transplants, whereas chest discomfort and dizziness are a common symptom after liver and kidney transplants. Yet, chest pain is not a typical symptom after a heart transplant.

Meta-Analysis and Clinical Features of Perioperative Takotsubo Cardiomyopathy in Noncardiac Surgery

Perioperative takotsubo cardiomyopathy (pTCM) is an increasing condition defined as cardiomyopathy in the setting of emotional and physiologic stressors imposed by surgery. We aimed to classify and understand the presentation, management, and prognosis of noncardiac surgery pTCM in published cases. As such, a review of previous studies using the PubMed, Embase, Cochrane, and Web of Science databases was conducted to obtain case reports and series reporting noncardiac pTCM from inception to September 2022, and a crude analysis was conducted to classify the clinical features. Of the 1,002 studies, 96 met our inclusion criteria, of which 101 cases were extracted and included in the final systematic review. A total of 29.7% of cases occurred during general surgery and 20.8% during transplant procedures. The median age at presentation was 55 years, with a 42 to 65 interquartile range. The prevalence of hypertension and mood disorders were 22.8% and 9.9%, respectively. Before the procedures, physiologic stressors occurred more commonly than emotional stressors (20.8% and 11%, respectively). Objective findings, including ST-T-wave changes, new arrhythmias, and hypotension, were the most common initial presenting symptoms. Most cases occurred during emergence from surgery or on the first postoperative day. Mechanical circulatory support was required in 15.8% of the cases, and the all-cause in-hospital mortality was 6.9%. The ejection fraction and symptoms improved within a median of 2 weeks after diagnosis (interquartile range 1 to 6). In conclusion, the risk factors, triggers, and outcomes of pTCM appear to differ from those of classic nonperioperative TCM presentations. Future studies will help shed light on this more frequently diagnosed condition complicating some noncardiac surgical cases.

Takotsubo Syndrome in Orthotopic Liver Transplant: A Systematic Review and Pooled Analysis of Published Studies and Case Reports

BACKGROUND

Takotsubo syndrome (TTS) has been reported in solid-organ transplant recipients. However, the pooled data regarding TTS after liver transplant remain limited.

METHODS

A systematic review was performed through February 2022 using PubMed, Embase, Scopus, and Google Scholar to review case reports/series and original studies on liver transplant-associated TTS. Descriptive analysis was performed for case reports and pooled analysis for the prevalence using random effects models.

RESULTS

A total of 56 case reports were included from 30 articles (51.8 % male; mean age, 53 years; India 56%, US 27%, and Europe 8.93%) and 10 original studies (US 88.65%, India 10.92%) revealing liver transplant-associated TTS. The pooled prevalence of TTS was 1.1% (95% Cl, 0.6%-1.7%) of all liver transplants with comparable rates in studies from India and the US (P = .92). Indications for liver transplant included end-stage liver disease due to alcohol-related cirrhosis (25%), hepatitis C virus infection (17.9%), hepatocellular carcinoma (10.7%), and non-alcohol-related steatohepatitis (8.9%); the average Model for End-Stage Liver Disease score was 24.75. TTS commonly presented as hypotension (30%), dyspnea (14%), and oliguria, occurring mostly post-transplant (82%), whereas 14% were intraoperative. Common electrocardiogram findings were ST changes, ventricular tachycardia, and atrial fibrillation. Common echocardiogram findings showed left ventricular apical ballooning in 46.5% of cases and reduced ejection fraction < 20% in 41.9% of cases. Common complications were cardiogenic shock (32.1 %), acute kidney injury (12.5%), arrhythmia, stroke, cardiac arrest, and hepatic artery thrombosis. Mechanical circulatory support was required in 30.3%. Recurrence was reported in 15, and mortality in 30.4% of patients.

CONCLUSIONS

Takotsubo syndrome prevalence after liver transplant is significantly higher than TTS prevalence in general US hospitalizations with potentially worse outcomes. Prospective registries reporting TTS in liver transplant recipients are warranted.

Update of Takotsubo cardiomyopathy: Present experience and outlook for the future

Takotsubo cardiomyopathy (TTS) has become a recognised clinical entity since the Japanese scientist Sato first described it in 1990. Despite an increasing number of confirmed cases, especially during the COVID-19 pandemic, its pathophysiology remains incompletely understood, and decision-making differs in the diagnosis and treatment. In addition, it is not evident whether a significant increase in TTS is due to better understanding among practitioners and widespread access to coronary angiography, or if it is a reflection of an actual increase in incidence. We analysed a series of international research studies from 1990 to 2021. Beyond epidemiology and clinical presentation, we evaluated and summarised fundamental knowledge about various predisposing factors, with particular attention to the iatrogenic impact of certain drugs, namely antidepressants, chemotherapy, and antiarrhythmics. Furthermore, we highlighted the main pathophysiological theories to date. In addition, based on published studies and clinical cases, we investigated the role of numerous diagnostic approaches in the differential diagnosis of TTS and identified predictors of TTS complications, such as cardiogenic shock, ventricular fibrillation, and left ventricular thrombi. Accordingly, we sought to propose a diagnostic algorithm and further treatment management of TTS under the presence of possible complications to help practitioners make more informed decisions, as the initial presentation continues to pose a challenge due to its close similarity to acute coronary syndrome with ST-elevation. In conclusion, this article examines Takotsubo cardiomyopathy from different perspectives and, along with future systematic reviews and meta-analyses, can be of particular interest to practising cardiologists and researchers in developing clinical guidelines.