1
|
Madias JE. Left ventricular outflow tract obstruction/hypertrophic cardiomyopathy/takotsubo syndrome: A new hypothesis of takotsubo syndrome pathophysiology. Curr Probl Cardiol 2024; 49:102668. [PMID: 38797507 DOI: 10.1016/j.cpcardiol.2024.102668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Accepted: 05/20/2024] [Indexed: 05/29/2024]
Abstract
The pathophysiology of TTS is still elusive. This viewpoint proposes that TTS is an acute coronary syndrome, engendered by an ASNS/catecholamine-induced LVOTO, which results in an enhanced wall stress and afterload-based supply/demand mismatch, culminating in a segmental myocardial ischemic injury state, in susceptible individuals. Such individuals are felt to be particularly women with chronic hypertension, known or latent HCM, or non-HCM segmental myocardial hypertrophy, and certain structural abnormalities involving the LV and the MV apparatus. Recommendations are provided to explore further this hypothesis, while maintaining our focus on all other advanced TTS pathophysiology hypotheses for all patients, or those who do not experience LVOTO, men, the young, and patients with reverse, mid-ventricular, or right ventricular TTS, in whom more prolonged hyperadrenergic stimulation and/or larger amounts of blood-ridden catecholamines, segmental particularities of cardiac innervation and/or density of α-, and β-adrenergic receptors, pheochromocytoma, neurological chronic or acute comorbidities/catastrophies, coronary epicardial/microvascular vasospasm, and CMD.
Collapse
Affiliation(s)
- John E Madias
- From the Icahn School of Medicine at Mount Sinai, New York, NY, United States; Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States.
| |
Collapse
|
2
|
Kabadi RA, Shah M, Marhefka GD, George G, Awsare B, Terai M, Sato T. Rapid, Fatal Acute Right Ventricular Failure After Locoregional Cytokine Therapy for Uveal Melanoma Liver Metastases. Tex Heart Inst J 2021; 47:224-228. [PMID: 32997782 DOI: 10.14503/thij-18-6762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Locoregional cytokine treatment, or immunoembolization, is an experimental targeted therapy for uveal melanoma metastatic to the liver. Unlike systemic cytokine treatments that have been associated with substantial toxicity, this method of drug delivery appears to be better tolerated. Because this newer therapy is being prescribed more widely, oncologists, interventional radiologists, cardiologists, pulmonologists, critical care specialists, and other providers should become familiar with potential adverse reactions. We describe the case of a 67-year-old man who had metastatic uveal melanoma. Before he underwent liver-directed immunoembolization, he had elevated markers of endothelial dysfunction. He died after the rapid onset of acute right ventricular failure from severe pulmonary hypertension with possible superimposed isolated right ventricular takotsubo cardiomyopathy. In discussing this rare case, we focus on the differential diagnosis.
Collapse
Affiliation(s)
- Rajiv A Kabadi
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107
| | - Mital Shah
- Department of Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107
| | - Gregary D Marhefka
- Department of Medicine, Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107
| | - Gautam George
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107
| | - Bharat Awsare
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania 19107
| | | | | |
Collapse
|
3
|
Takotsubo cardiomyopathy and its relevance to anesthesiology: a narrative review. Can J Anaesth 2016; 63:1059-74. [DOI: 10.1007/s12630-016-0680-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Revised: 04/21/2016] [Accepted: 06/02/2016] [Indexed: 12/14/2022] Open
|
4
|
Rostagno C, Cammilli A, Di Cristo A, Polidori GL, Ranalli C, Cartei A, Buzzi R, Prisco D. Acute coronary syndromes with significant troponin increase in patients with hip fracture prior to surgical repair: differential diagnosis and clinical implications. Intern Emerg Med 2016; 11:219-24. [PMID: 26563767 DOI: 10.1007/s11739-015-1348-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2015] [Accepted: 10/28/2015] [Indexed: 11/27/2022]
Abstract
Myocardial infarction after hip fracture but before surgical repair is associated with a 30-day mortality as high as 30 % at 1 month. In Florence, since 2011, hip fractures are referred to a multidisciplinary hip fracture team including internal medicine specialists, anesthesiologists, and orthopaedic surgeons. The aim of the present investigation was to evaluate the clinical characteristics of patients with hip fracture who had at hospital admission a significant increase of troponin (>10 times reference levels), the diagnostic and therapeutic strategies adopted, and overall 1-year survival. Protocol at admission included careful clinical evaluation (including bedside echocardiography) in order to stratify surgical risk and schedule surgery and anaesthesiology strategy. 21/1025 patients had preoperative significant troponin increase. In sixteen patients, a diagnosis of NSTEMI was made, five presented with ST elevation. In five patients with NSTEMI considered at very high surgical risk (ASA ≥ 3, severe cognitive and functional impairment), surgery was not performed. None survived at 1 year. Hip surgery was performed in the other 11. Four underwent coronary revascularization after hip surgery. In this group, 1-year survival was 80 %. Four of five ST elevation patients fulfilled criteria for stress cardiomyopathy confirmed by angiography. Hip surgery was performed, and the patients are alive at 1-year follow-up. Close to 2 % of patients with hip fracture are found to have a significant troponin increase before surgery. Three out of four have an NSTEMI diagnosis. In patients undergoing hip surgery, survival at 1 year is close to 80 %. In patients with ST elevation at admission, stress cardiomyopathy should be considered in the differential diagnosis. This clinical condition is associated with a favourable prognosis after hip surgery.
Collapse
Affiliation(s)
- Carlo Rostagno
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Viale Morgagni 85, 50134, Florence, Italy.
- SOD Medicina Interna e Post Chirurgica AOU Careggi, Florence, Italy.
| | | | | | | | - Claudia Ranalli
- SOD Medicina Interna e Post Chirurgica AOU Careggi, Florence, Italy
| | | | - Roberto Buzzi
- SOD Traumatologia ed Ortopedia AOU Careggi, Florence, Italy
| | - Domenico Prisco
- Dipartimento Medicina Sperimentale e Clinica, Università di Firenze, Viale Morgagni 85, 50134, Florence, Italy
| |
Collapse
|
5
|
Mazzola P, Picone D, Anzuini A, Corsi M, Bellelli G, Annoni G. Takotsubo cardiomyopathy in an 81-year-old woman after injection of bone cement during hemiarthroplasty: An orthogeriatric case report. Int J Surg Case Rep 2015; 18:37-41. [PMID: 26688511 PMCID: PMC4701876 DOI: 10.1016/j.ijscr.2015.11.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION Takotsubo cardiomyopathy is a syndrome characterized by transient cardiac ischemia-like symptoms, such as chest pain, increase of myocardial necrosis markers, electrocardiographic changes, and temporary left ventricular apical ballooning without significant coronary artery disease, often triggered by a particularly stressful situation. The association between Takotsubo and hip fracture surgery has been rarely reported in the literature. PRESENTATION OF CASE An 81-year-old woman was hospitalized with a diagnosis of right femoral neck fracture. During the surgical procedure, she displayed acute coronary symptoms a few minutes after the injection of bone cement, in the absence of coronary lesions. Due to the time relationship, bone cement implantation syndrome - not uncommon to observe - was considered in the differential diagnosis. However, the instrumental findings and the transient nature of the abnormalities guided us toward a diagnosis of Takotsubo. The treatment with Levosimendan, Amiodarone, and Metoprolol allowed gradual and satisfactory recovery of the cardiac function within a few days. The follow-up performed two and six months after surgery revealed complete cardiac recovery, and ability to walk at home comparable to the pre-fracture situation. DISCUSSION Takotsubo cardiomyopathy is more common in women during the postmenopausal phase, especially if undergoing stressful physical or emotional stimuli. In this case, the sequence of hip fracture, pain, hospitalization, and surgery could easily be intended as a strong stressful event with high physical/psychological burden. CONCLUSION Despite the good prognosis associated with early recognition, Takotsubo represents a life-threatening adverse event. Considering its possible pathogenesis, a "gentle care" approach and the optimization of pain control must be pursued in elderly subjects with hip fracture, aiming at reducing the stress of the hospitalization and related procedures.
Collapse
Affiliation(s)
- Paolo Mazzola
- Department of Medicine and Surgery, University of Milano-Bicocca and Geriatric Clinic, San Gerardo University Hospital, 20900 Monza-MB, Italy; NeuroMI-Milan Center for Neuroscience, Clinical Neurosciences Research Area, 20126 Milano-MI, Italy.
| | - Domenico Picone
- Department of Medicine and Surgery, University of Milano-Bicocca and Geriatric Clinic, San Gerardo University Hospital, 20900 Monza-MB, Italy
| | - Alessandra Anzuini
- Department of Medicine and Surgery, University of Milano-Bicocca and Geriatric Clinic, San Gerardo University Hospital, 20900 Monza-MB, Italy
| | - Maurizio Corsi
- Department of Medicine and Surgery, University of Milano-Bicocca and Geriatric Clinic, San Gerardo University Hospital, 20900 Monza-MB, Italy
| | - Giuseppe Bellelli
- Department of Medicine and Surgery, University of Milano-Bicocca and Geriatric Clinic, San Gerardo University Hospital, 20900 Monza-MB, Italy; NeuroMI-Milan Center for Neuroscience, Clinical Neurosciences Research Area, 20126 Milano-MI, Italy
| | - Giorgio Annoni
- Department of Medicine and Surgery, University of Milano-Bicocca and Geriatric Clinic, San Gerardo University Hospital, 20900 Monza-MB, Italy; NeuroMI-Milan Center for Neuroscience, Clinical Neurosciences Research Area, 20126 Milano-MI, Italy
| |
Collapse
|
6
|
Risk factors associated with acute heart failure during liver transplant surgery: a case control study. Transplantation 2015; 99:873-8. [PMID: 25208319 DOI: 10.1097/tp.0000000000000387] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Acute intraoperative heart failure (HF) is a rare but often fatal complication of liver transplant surgery. Little is known about the clinical course or predictive variables. Our aims were to provide a detailed clinical description and conduct a systematic search for characteristics associated with intraoperative HF. METHODS A matched case-control study of adults undergoing primary liver transplant from 2009 to 2011 was conducted. Cases showed new onset HF with an ejection fraction less than 50% during liver transplant surgery. Controls were recipients without signs or symptoms of HF. Matching was based on: age, sex, model for end-stage liver disease at the time of transplant, type 2 diabetes, and β-blocker use. Conditional logistic regression analyses were conducted. RESULTS From 2009 to 2011, seven (3%) of 256 recipients developed intraoperative HF with one resulting death. All survivors regained normal systolic function within 6 months of surgery. Decreasing preoperative serum sodium (odds ratio, 1.41; 95% confidence interval, 1.02-1.94; P = 0.039) and increasing number of units of packed red blood cells transfused intraoperatively (odds ratio=1.2, 95% confidence interval, 1.001-1.467, P = 0.048) were associated with HF. CONCLUSION No preoperative echocardiographic parameter predicted HF in affected patients. Two possible explanations are: our patients suffered from stress cardiomyopathy and therefore had no evidence of impaired contraction before the event or echocardiographic predictors of HF were masked by circulatory changes in patients with cirrhosis. Lower serum sodium and more red blood cell transfusions were associated with intraoperative HF. Lower mortality of our intraoperative cases compared to others may be influenced by earlier diagnosis and intervention.
Collapse
|
7
|
Patel B, Assad D, Wiemann C, Zughaib M. Repeated use of albuterol inhaler as a potential cause of Takotsubo cardiomyopathy. AMERICAN JOURNAL OF CASE REPORTS 2014; 15:221-5. [PMID: 24855502 PMCID: PMC4029766 DOI: 10.12659/ajcr.890388] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2014] [Accepted: 02/12/2014] [Indexed: 01/01/2023]
Abstract
Patient: Female, 78 Final Diagnosis: Takotsubo cardiomyopathy Symptoms: Chest discomfort, chest pain, dyspnea, short of breath Medication: — Clinical Procedure: — Specialty: Cardiology
Collapse
Affiliation(s)
- Brijesh Patel
- Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, MI, U.S.A
| | - Dania Assad
- Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, MI, U.S.A
| | - Charlotte Wiemann
- Department of Internal Medicine, Providence Hospital and Medical Center, Southfield, MI, U.S.A
| | - Marcel Zughaib
- Department of Cardiology, Providence Hospital and Medical Center, Southfield, MI, U.S.A
| |
Collapse
|
8
|
“Nipple” and “hawk's beak” appearances on contrast left ventricular angiography in Takotsubo syndrome: What's in a sign? Int J Cardiol 2014; 173:326. [DOI: 10.1016/j.ijcard.2014.03.053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 03/09/2014] [Indexed: 11/18/2022]
|