Comparison and outcome analysis of patients with apical and non-apical takotsubo cardiomyopathy

BACKGROUND

Takotsubo cardiomyopathy (TTC) is a relevant differential diagnosis in patients presenting with signs of an acute coronary syndrome. Although recent literature has highlighted some salient features of this disorder, there has been little information elucidating the differences in clinical features, electrocardiographic findings, echocardiographic data and TTC-related complications associated with the different variants of TTC.

METHODS AND RESULTS

Our institutional database constituted a collective of 114 patients diagnosed with TTC between 2003 and 2015 and these patients were subsequently divided into two groups based on the presence (n = 82, 72%) or absence (n = 32, 28%) of the apical form of TTC. The protocol for our proposed study was approved by the Ethics Committee of the University Medical Centre in Mannheim. It was noticed that the patients presenting with the apical form of TTC belonged to an older age group as compared to those presenting with the non-apical form (61.1 ± 8.9 years vs. 69.5 ± 11.2; P  < 0.01). The QTc interval prolongation at index-event was observed to be quantifiably greater in the 'apical variant' patients group (484.8 ± 57 ms vs. 464 ± 34.1 ms; P = 0.06). With respect to cardiovascular risk factors, patients with arterial hypertension did have a higher predilection to present with the apical form (63.4% vs. 43.7%; P = 0.06), however, the impact of smoking was less pronounced in this patient group (24.4% vs. 50%, P = 0.01). Furthermore, our study highlighted a significant impact on ejection fraction (EF), with a compromised left ventricular function (36 ± 9% vs. 42.4 ± 9.7%, P < 0.01) and greater involvement of the right ventricle in the apical variant patients group (23% vs. 3%, P = 0.04). Patients with the apical form also showed a greater tendency to develop TTC-related complications such as cardiogenic shock and required longer monitoring and care in comparison.

CONCLUSIONS

The apical and non-apical variants of TTC are manifestations of the same syndrome. They differ significantly, however, in their clinical presentation, related complications and prognosis.

Prevalence, Clinical Characteristics, and Predictors of Patients with Thromboembolic Events in Takotsubo Cardiomyopathy

BACKGROUND

Several acute complications related to takotsubo cardiomyopathy (TTC) have been documented recently. However, the incidence and clinical significance of acute thromboembolic events in TTC is not well established.

METHODS

A detailed investigation of the clinical characteristics and in-hospital complications of 114 consecutive patients diagnosed with TTC between January 2003 and September 2015 was carried out. This study was initiated to reveal the predictors, clinical significance, and short-term and long-term outcomes of patients with TTC associated with acute thromboembolic events on index presentation.

RESULTS

The incidence of acute thromboembolic events related to TTC was around 12.2%, and these included ventricular thrombi, cerebrovascular events, retinal and brachial artery pathologies, renal, splenic, and aortic involvement. The most frequent complication on initial presentation was cardiogenic shock (20%) accompanied with pulmonary congestion (20%). Interestingly, patients experiencing thromboembolic events had higher C-reactive protein (CRP) levels as compared to the non-thromboembolic group (P = 0.02). Certain thromboembolic events were characterized by the presence of ST-segment elevation in electrocardiogram (P = 0.02). Chest pain was the primary symptom in these patients (P = 0.09). Furthermore, there was significant right ventricular involvement (as assessed by transthoracic echocardiography) in patients presenting with an acute thromboembolic event (P = 0.08). A Kaplan–Meier analysis indicated a significantly higher mortality rate over a mean follow-up of three years in the thromboembolic group than the non-thromboembolic group (log-rank, P = 0.02).

CONCLUSIONS

Our results confirmed the relative common occurrence of thromboembolic events in the setting of TTC. Inflammation might play an important role in the development of thromboembolic events, and a right ventricular involvement and ST-segment elevation could be positive predictors for this occurrence. In order to circumvent the risk of a negative outcome, it is recommended that an anticoagulation therapy be initiated in all high-risk patients.

Cardiac Function After Multimodal Breast Cancer Therapy Assessed With Functional Magnetic Resonance Imaging and Echocardiography Imaging

PURPOSE

Breast intensity modulated radiation therapy (IMRT) reduces high-dose heart volumes but increases low-dose volumes. We prospectively assessed heart changes after 3D conformal RT (3DCRT) and IMRT for left-sided breast cancer. Heart dose was analyzed individually, 3DCRT patients were moderately exposed, and IMRT was performed only in patients with unacceptably high heart doses upon 3DCRT planning.

METHODS AND MATERIALS

In 49 patients (38 patients received 3DCRT; 11 patients received IMRT; and 20 patients received neoadjuvant or adjuvant chemotherapy) magnetic resonance imaging (MRI) and echocardiography were performed before and at 6, 12, and 24 months after treatment.

RESULTS

Mean heart dose for IMRT was 12.9 ± 3.9 Gy versus 4.5 ± 2.4 Gy for 3DCRT. Heart volumes receiving >40 Gy were 2.6% (3DCRT) versus 1.3% (IMRT); doses were >50 Gy only with 3DCRT. Temporary ejection fraction (EF) decrease was observed on MRI after 6 months (63%-59%, P=.005) resolving at 24 months. Only 3 patients had pronounced largely transient changes of EF and left ventricular enddiastolic diameter (LVEDD). Mitral (M) and tricuspid (T) annular plane systolic excursion (MAPSE and TAPSE) were reduced over the whole cohort (still within normal range). After 24 months left ventricular remodeling index decreased in patients receiving chemotherapy (0.80 vs 0.70, P=.028). Neither wall motion abnormalities nor late enhancements were found. On echocardiography, in addition to EF findings that were similar to those on MRI, global strain was unchanged over the whole cohort at 24 months after a transient decrease at 6 and 12 months. Longitudinal strain decreased in the whole cohort after 24 months in some segments, whereas it increased in others.

CONCLUSIONS

Until 24 months after risk-adapted modern multimodal adjuvant therapy, only subclinical cardiac changes were observed in both 3DCRT patients with inclusion of small to moderate amounts of heart volume in RT tangents and in the patients treated with IMRT and reduced high-dose heart exposure.

Mitral annular plane systolic excursion is an easy tool for fibrosis detection by late gadolinium enhancement cardiovascular magnetic resonance imaging in patients with hypertrophic cardiomyopathy

BACKGROUND

Hypertrophic cardiomyopathy (HCM) causes various degrees of fibrosis resulting in left ventricular function impairment, which can be measured using mitral annular plane systolic excursion (MAPSE).

AIMS

To determine the values for septal, lateral and average MAPSE using cardiovascular magnetic resonance (CMR) in healthy controls and patients with HCM; and to investigate whether MAPSE correlated with the extent of fibrosis.

METHODS

Patients with HCM and healthy controls underwent CMR.

RESULTS

In 50 healthy controls, septal and lateral MAPSE were comparable and showed excellent intra- and inter-observer reliability. Patients with HCM had significantly reduced septal, lateral and average MAPSE compared to healthy controls. Furthermore, in patients with HCM, septal MAPSE measurements were significantly reduced compared to lateral ones. Correspondingly, the septal myocardial segments showed significantly more late gadolinium enhancement (LGE) than lateral ones. No significant differences were found between echocardiographic and CMR MAPSE measurements in healthy controls and patients with HCM. Patients who suffered a major adverse cardiac event or stroke revealed a significantly reduced MAPSE and a significantly greater LGE extent compared to event-free patients with HCM.

CONCLUSIONS

MAPSE measurement using CMR is feasible, reproducible and comparable to echocardiography in healthy controls and patients with HCM. The asymmetric and mainly septal distribution of myocardial hypertrophy and fibrosis detected by LGE in patients with HCM was reflected by significantly reduced septal versus lateral MAPSE. Therefore, reduced MAPSE seems to be an easily determinable marker of fibrosis accumulation leading to left ventricular mechanical dysfunction and also seems to have a prognostic implication.

Long term impact of cardiac contractility modulation on QRS duration

BACKGROUND AND PURPOSE

Cardiac contractility modulation (CCM) is an implantable device treatment for heart failure with reduced ejection fraction. CCM therapy improves patient functional status but its effect on intra-ventricular conduction remains unknown.

METHODS

70 patients treated with CCM between 12/2002 and 5/2013 had 12-vector-ECG recordings made at baseline and final follow-up visits. QRS complex duration was measured at each time point.

RESULTS

Mean follow-up was 2.8 years. Mean QRS duration was unchanged from baseline (112.0 ms) to last follow up (112.9 ms, p=n.s.). These results are strikingly different from comparative published data of several studies with heart failure patients without CCM, consistently indicating an increase in QRS duration (6.0-23.4 ms) over a similar time period.

CONCLUSIONS

CCM prevents chronic ventricular depolarization delay that occurs in heart failure and that is associated with poorer outcomes. This supports the safety of long-term CCM therapy and suggests a possible long-term benefit in maintaining QRS duration.

Right ventricular function quantification in Takotsubo cardiomyopathy using two-dimensional strain echocardiography

Aims

This study sought to characterize global and regional right ventricular (RV) myocardial function in patients with Takotsubo cardiomyopathy (TC) using 2D strain imaging.

Methods

We compared various parameters of RV and left ventricular (LV) systolic function between 2 groups of consecutive patients with TC at initial presentation and upon follow-up. Group 1 had RV involvement and group 2 did not have RV involvement.

Results

At initial presentation, RV peak systolic longitudinal strain (RVPSS) and RV fractional area change (RVFAC) were significantly lower in group 1 (−13.2±8.6% vs. −21.8±5.4%, p = 0.001; 30.7±9.3% vs. 43.5±6.3%, p = 0.001) and improved significantly upon follow-up. Tricuspid annular plane systolic excursion (TAPSE) did not differ significantly at initial presentation between both groups (14.8±4.1 mm vs. 17.9±3.5 mm, p = 0.050). Differences in regional systolic RV strain were only observed in the mid and apical segments. LV ejection fraction (LVEF) and LV global strain were significantly lower in group 1 (36±8% vs. 46±10%, p = 0.006 and −5.5±4.8% vs. −10.2±6.2%, p = 0.040) at initial presentation. None of the parameters were significantly different between the 2 groups upon follow-up. A RVPSS cut-off value of >−19.1% had a sensitivity of 85% and a specificity of 71% to discriminate between the 2 groups.

Conclusion

In TC, RVFAC, RVPSS, LVEF and LV global strain differed significantly between patients with and without RV dysfunction, whereas TAPSE did not. 2 D strain imaging was feasible for the assessment of RV dysfunction in TC and could discriminate between patients with and without RV involvement in a clinically meaningful way.

Epicardial adipose tissue assessed by cardiac magnetic resonance imaging in patients with heart failure due to dilated cardiomyopathy

OBJECTIVE

We sought to investigate the association of the EAT with CMR parameters of ventricular remodelling and left ventricular (LV) dysfunction in patients with non-ischemic dilated cardiomyopathy (DCM).

DESIGN AND METHODS

One hundred and fifty subjects (112 consecutive patients with DCM and 48 healthy controls) underwent CMR examination. Function, volumes, dimensions, the LV remodelling index (LVRI), the presence of late gadolinium enhancement (LGE) and the amount of EAT were assessed.

RESULTS

Compared to healthy controls, patients with DCM revealed a significantly reduced indexed EAT mass (31.7 ± 5.6 g/m(2) vs 24.0 ± 7.5 g/m(2) , p<0.0001). There was no difference in the EAT mass between DCM patients with moderate and severe LV dysfunction (23.5 ± 9.8 g/m(2) vs 24.2 ± 6.6 g/m(2) , P = 0.7). Linear regression analysis in DCM patients showed that with increasing LV end-diastolic mass index (LV-EDMI) (r = 0.417, P < 0.0001), increasing LV end-diastolic volume index (r = 0.251, P = 0.01) and increasing LV end-diastolic diameter (r = 0.220, P = 0.02), there was also a significantly increased amount of EAT mass. However, there was no correlation between the EAT and the LV ejection fraction (r = 0.0085, P = 0.37), right ventricular ejection fraction (r = 0.049, P = 0.6), LVRI (r = 0.116, P = 0.2) and the extent of LGE % (r = 0.189, P = 0.1). Among the healthy controls, the amount of EAT only correlated with increasing age (r = 0.461, P = 0.001), BMI (r = 0.426, P = 0.003) and LV-EDMI (r = 0.346, P = 0.02).

CONCLUSION

In patients with DCM the amount of EAT is decreased compared to healthy controls irrespective of LV function impairment. However, an increase in LV mass and volumes is associated with a significantly increase in EAT in patients with DCM.

Evaluation of aortic valve stenosis using a hybrid approach of Doppler echocardiography and inert gas rebreathing

BACKGROUND

Doppler echocardiography is the method of choice for diagnosis and evaluation of aortic stenosis. However, there are well-known limitations to this method in difficult-to-image patients. Flow acceleration in the left ventricular outflow tract (LVOT) can lead to overestimation of stroke volume (SV) and poor acoustic windows may impede the exact measurement of the LVOT. The present study aimed to evaluate the use of inert gas rebreathing (IGR)-derived SV in this situation.

PATIENTS AND METHODS

We replaced Doppler-derived SV measurements in the continuity equation (method A) by SV determined by IGR (method B) and by thermodilution during right heart catheterization (method C) to calculate the aortic valve area (AVA) in 21 consecutive patients with moderate or severe aortic stenosis.

RESULTS

Mean SV and AVA did not differ between methods at 72±21 ml and 0.71±0.2 cm(2) (method A) vs. 66±18 ml and 0.67±0.21 cm(2) (method B) vs. 64±15 ml and 0.67±0.21 cm(2) (method C), respectively (all p-values >0.05). The mean difference and limits of agreement for AVA were 0.04±0.23 cm(2) and -0.40 to 0.47 cm(2) between methods A and B, 0.05±0.14 cm(2) and -0.26 to 0.27 cm(2) between A and C, and -0.05±0.23 cm(2) and -0.45 to 0.35 cm(2) between B and C, respectively (all p-values >0.05).

CONCLUSION

The presented approach is a reliable method for the calculation of AVA and can add a diagnostic option for the use in difficult-to-image patients. Whereas the use of thermodilution is limited due to its invasive nature, IGR allows the fast and non-invasive determination of cardiac function at low cost.

[Is cardiotoxicity still an issue after breast-conserving surgery and could it be reduced by multifield IMRT?]

BACKGROUND

Postoperative radiotherapy after breast cancer surgery effectively reduces local relapses. A survival benefit after breast conservation, however, has only been proven recently which was in part due to excessive cardiac mortality of patients who had been treated with radiotherapy in the past.

MATERIAL AND METHODS

The literature on postoperative radiotherapy for breast cancer was reviewed with regard to cardiac toxicity as the basis for hypothesis generation.

RESULTS

From numerous publications on cardiac toxicity of breast cancer radiotherapy, the following pattern emerges: in series where a high radiation dose was applied to a significant percentage of the heart (postmastectomy and postlumpectomy series) cardiac toxicity/mortality was increased versus a nonexposed cohort or for left over right disease. If, however, a relevant exposure of cardiac muscle could be more or less excluded based on the technique used (mainly more recent postlumpectomy radiotherapy), no cardiac toxicity was observed. Series for which individual dose exposure varied or could not be clarified also came to varying conclusions. Also due to retrospectively unclear dose distributions, an exact quantification of tolerance doses/effects of different geographic dose distribution patterns could not be performed to date. A particularly difficult question to answer is the threshold volume for clinically relevant cardiotoxicity with tangential radiotherapy at prescription doses. As a consequence, this precludes an estimate in which situations multifield intensity-modulated radiotherapy (IMRT) with its characteristic dose distribution pattern of a larger volume exposed to intermediate doses and higher mean/median heart doses (as shown in Figure 1) might be preferable.

CONCLUSION

This review updates the database on cardiac toxicity of breast cancer radiotherapy with special emphasis regarding the issues related to the clinical use of IMRT. Multifield IMRT may reduce the cardiac risk for a small subset of patients at excessive risk with conventional tangential radiotherapy due to unfavorable thoracic geometry, for whom partial-breast radiotherapy is not an option. Due to further concern about the effects of intermediate doses to larger heart volumes, potentially increased contralateral cancer risk and the long latency of clinically apparent toxicity, the introduction of breast IMRT should be closely followed. Accompanying functional studies may have the potential to detect cardiac toxicity at an earlier time.

Incidence and clinical significance of left ventricular thrombus in tako-tsubo cardiomyopathy assessed with echocardiography

BACKGROUND

Left ventricular (LV) thrombus is a known complication of tako-tsubo cardiomyopathy (TC). However, current literature almost exclusively consists of isolated case reports. The aim of this study was to determine the incidence and clinical significance of LV thrombus formation in TC.

METHODS AND RESULTS

Over a 33-month period 52 patients with TC were assembled into a database at our institution. A retrospective database search was performed to identify patients with LV thrombus among these patients. LV thrombus, by echocardiography, was discovered in four patients[(8%); 95% confidence interval 3-19%]. Thrombus was present at the time of diagnosis in three patients. In one patient thrombus was absent initially and developed later. The LV apex was the site of thrombus formation in two patients, but the true apex was spared in the other two. All four patients had elevated serum levels of C-reactive protein (CRP). Two patients also had thrombocytosis. Treatment with low molecular weight heparin (LMWH) led to resolution of thrombus in all cases.

CONCLUSION

Our findings suggest that LV thrombus is a noteworthy complication in TC. It can occur both at initial presentation or at anytime later during the disease course. Elevated CRP levels and thrombocytosis may indicate a higher risk of thrombus formation.