A case of takotsubo-shaped hypokinesis of the left ventricle caused by a lightning strike

Takotsubo syndrome associated with cardioversion: a systematic review

Background

Direct current cardioversion is a well-established and safe procedure to restore normal sinus rhythm for atrial and ventricular arrhythmias. Takotsubo syndrome has been rarely described with cardioversion. We reviewed the literature for descriptions of Takotsubo syndrome associated with the stress of cardioversion, to better understand its risks.

Methods

We queried MEDLINE, EMBASE, Google Scholar and Cochrane for cases of Takotsubo syndrome secondary to synchronized cardioversion as defined by Mayo Clinic Diagnostic Criteria.

Results

We identified 11 cases of cardioversion-associated Takotsubo syndrome. Average age was 76 years (range: 61–87 years) and most (10 out of 11, 91%) were female. Diagnosis was made soon after cardioversion (median: 10 h, range: 0–48 h). Only 2 of 11 had ST elevations noted, while apical ballooning was noted in all cases. Pulmonary edema developed in 6 and cardiogenic shock developed in 5 patients. The median recovery time was 7 days (range: 3–11).

Conclusions

Cardioversion-associated TS has an overall favorable outcome with complete recovery in most cases. A higher risk of this complication may exist for elderly females undergoing synchronized cardioversion.

Use of troponin assay after electrical injuries: a 15-year multicentre retrospective cohort in emergency departments

Background

Patients with electrical injury are considered to be at risk of cardiac arrhythmia. Assessing the risk of developing a major adverse cardiac event (MACE) is the cornerstone of patient management. The aim of this study was to assess the performance of initial troponin and troponin rise to predict Major Adverse Cardiac Events (MACEs) in all patients with electrical injuries admitted to the Emergency Department.

Methods

This is a multicentre retrospective study in which consecutive patients with electrical injuries admitted to the Emergency Departments (ED) (adult and paediatric) of five French Hospitals were included between 2005 and 2019. The threshold for troponin elevation is based on the European Society of Cardiology guidelines for patients presenting without persistent ST segment elevation. The primary endpoint was the rate of MACE.

Results

A total of 785 included patients were admitted to ED with a first diagnosis of electrical injury during the study period. Troponin assays were performed in 533 patients (67.9%), including 465 of 663 adults (70.1%) and 68 of 122 children (55.7%) and 17/533 (3.2%) of patients had an initial elevated troponin. If none of the clinical criteria for MACE were present (i.e., previous known heart disease, exposure to a high voltage of ≥ 1000 Volts, initial loss of consciousness, or an abnormal initial ECG), this defined a low-risk subgroup (n = 573, 76.0%) that could be safely discharged. The initial positive troponin assay had a sensitivity of 83.3 (95% CI 35.9–99.6%), a specificity of 97.7 (95% CI 96.1–98.8%), a positive likelihood ratio 36.6 (95% CI 18.8–71.1%) and a negative predictive value of 99.9 (95% CI 99.2–99.9%) in predicting a MACE.

Conclusions

Troponin assay appears to be a predictive marker of MACE risk and should be considered in high-risk patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13049-021-00955-6.

Lightning Injury with Multi-System Involvement

Lightning leads to trauma and disability such as burns, hearing loss, blindness, cardiac arrhythmia, cardiac arrest, stroke, kidney injury, and can also lead to death. Such cases are seldom reported, and hence their database is scanty. We present a case of a 40-year-old female with lightning injury with four such manifestations, which is not commonly encountered. We have elaborated on these complications of lightning injury and their timely management, which has led us to good patient outcome.

Acute Inferior Myocardial Infarction Caused by Lightning Strike

Lightning strike is an infrequent natural phenomenon with serious medical complications, like multiple organ damage, and it is associated with increased risk of mortality. Cardiovascular complications are among the most hazardous complications of lightning strike. Lightning strike can cause various serious consequences ranging from electrocardiographic changes to death. We reported a 21-year-old patient with no cardiovascular risk factors struck by lightning and presented by inferior ST elevated myocardial infarction (MI). The patient was followed up in the intensive care unit and MI complication did not develop during follow-up. The patient was lost due to multi-organ failure after 20 hours. AydinF, Turgay YildirimO, DagtekinE, Huseyinoglu AydinA, AksitE. Acute inferior myocardial infarction caused by lightning strike. Prehosp Disaster Med. 2018;33(6):658-659.

Myocardial Stunning After Electrocution With Complete Reversibility Within 24 Hours: Role of Repeat Transthoracic Echocardiograms in Potential Cardiac Transplant Donors

Despite the development of ventricular assist devices, cardiac transplantation remains an important procedure for patients with advanced heart failure. The number of transplants done annually has remained stable because of lack of of donors. Left ventricular systolic dysfunction remains one of the most important reasons for seeking a donor heart. Myocardial stunning is an important cause of reversible systolic dysfunction. Electrical injury is a recognized cause of myocardial stunning with variable duration ranging from days to weeks. Repeating the transthoracic echocardiogram to look for reversibility of left ventricular dysfunction can be a cost-effective method to improve the selection of heart donors. This can significantly help to decrease critical organ shortage. We present a case of myocardial stunning after electrocution which was completely reversible within a few hours, thus meeting cardiac transplant donor criteria.

Cardiac Effects of Lightning Strikes

Lightning strikes are a common and leading cause of morbidity and mortality. Multiple organ systems can be involved, though the effects of the electrical current on the cardiovascular system are one of the main modes leading to cardiorespiratory arrest in these patients. Cardiac effects of lightning strikes can be transient or persistent, and include benign or life-threatening arrhythmias, inappropriate therapies from cardiac implantable electronic devices, cardiac ischaemia, myocardial contusion, pericardial disease, aortic injury, as well as cardiomyopathy with associated ventricular failure. Prolonged resuscitation can lead to favourable outcomes especially in young and previously healthy victims.

Tako-tsubo cardiomyopathy triggered by multiple shocks in electrical storm

Tako-tsubo cardiomyopathy (TTC) is a syndrome characterized by acute transient ventricular dysfunction in the absence of obstructive coronary artery disease and is predominantly associated with exposure to sudden emotional or physical stress. Patients with TTC may develop serious in-hospital complications, including ventricular arrhythmias. However, triggering of TTC after an electrical storm has not previously been described. We present two cases of TTC induced by multiple shocks in the setting of an electrical storm due to pharmacologically induced long QT syndrome.

Takotsubo cardiomyopathy as a sequela of elective direct-current cardioversion for atrial fibrillation

In takotsubo cardiomyopathy, the clinical appearance is that of an acute myocardial infarction in the absence of obstructive coronary artery disease, with apical ballooning of the left ventricle. The condition is usually precipitated by a stressful physical or psychological experience. The mechanism is unknown but is thought to be related to catecholamine excess. We present the case of a 67-year-old woman who experienced cardiogenic shock caused by takotsubo cardiomyopathy, immediately after undergoing elective direct-current cardio-version for atrial fibrillation. After a course complicated by left ventricular failure, cardiogenic shock, and ventricular tachycardia, she made a complete clinical and echocardiographic recovery. In addition to this case, we discuss the possible direct effect of cardioversion in takotsubo cardiomyopathy.

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.

A new ECG criterion to identify takotsubo cardiomyopathy from anterior myocardial infarction: role of inferior leads

With the exception of contrast-enhanced cardiovascular magnetic resonance imaging, clear distinction of takotsubo cardiomyopathy from anterior wall myocardial infarction cannot be achieved currently by simple and noninvasive tests. The aim of this study was to examine the role of inferior ECG leads in distinguishing these two conditions. From January 2004 to June 2006, eight female patients suffering from takotsubo cardiomyopathy were identified by the Mayo Clinic criteria. The clinical and ECG features were compared with 27 consecutive sex- and age-matched patients with anterior wall myocardial infarction admitted to the Coronary Care Unit within the same period. The observed ECG features were then verified with that of 62 published cases of takotsubo cardiomyopathy. Takotsubo cardiomyopathy patients had similar left ventricular ejection fraction (35.0% +/- 5.7% vs 38.2% +/- 6.4%, P = 0.829), lower peak creatinine kinase level (461 +/- 330 U/l vs 2723 +/- 1826 U/l, P = 0.020), more ST-segment elevation in the inferior leads (50% vs 7.4%, P = 0.016), and virtually no ST-segment depression in inferior leads (0% vs 48.2%, P = 0.015) compared with patients who had anterior wall myocardial infarction. ST-segment elevation of >or=1.0 mm in lead II had 62.5% sensitivity and 92.6% specificity in detecting takotsubo cardiomyopathy. The observed ECG characteristics were comparable with those in the literature. In patients who present with anterior wall myocardial infarction, the absence of ST-segment depression or ST-segment elevation in inferior leads, especially if the ST-segment in lead II >or= III, is highly suggestive of takotsubo cardiomyopathy.

[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 acute myocardial infarction due to indirect lightning strike

Lightning strike is a natural phenomenon with potentially devastating effects and represents one of the leading causes of cardiac arrest and death from environmental phenomena. Almost every organ system may be impaired as lightning passes through the human body preferring the pathways that the lowest resistance between the contact points. Lightning can also have widespread effects on the cardiovascular system, producing extensive catecholamine release or autonomic stimulation. The victim may develop hypertension, tachycardia, nonspecific electrocardiographic changes (including prolongation of the QT interval and transient T-wave inversion), and myocardial necrosis with release of creatine phosphokinase-MB fraction. We present the case of a 13-year-old boy with acute myocardial infarction secondary to an indirect lightning strike.