Transient left ventricular ballooning syndrome

The transient left ventricular apical ballooning syndrome or takotsubo-like left ventricular dysfunction refers to the ventricular morphological features present in the heart of these patients. It resembles the Japanese Takotsubo, which means a “fishing pot for trapping octopuses”. This syndrome is characterized by transient left ventricular dysfunction, electrocardiographic changes and minimal release of myocardial enzymes that mimic acute anterior myocardial infarction, in patients without angiographic coronary artery disease.Several pathophysiological mechanisms have been proposed to explain it; however the precise aetiology remains unknown. This condition is transient and has a good prognosis, however Takotsubo cardiomyopathy as a new entity of acute heart failure, should be noted and thought of as a cause of sudden cardiac death. Its proper diagnosis and management greatly depends on our initial suspicion.     

Unique phenotypes of typical and inverted Takotsubo cardiomyopathy in young females

Takotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient left ventricular regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, electrocardiographic changes and minor elevations of cardiac enzyme level in the absence of coronary artery disease. We present 3 cases of a transient cardiomyopathy, noted in young women with associated emotional, physical or pharmacologic triggering events, that are distinct in that they all manifested initially with acute pulmonary edema with systolic akinesis involving different LV segments with rapid recovery. It is a reversible cardiac condition that should be differentiated from ischemic and peripartum cardiomyopathy.     

Takotsubo cardiomyopathy followed by neurogenic stunned myocardium in the same patient: gradations of the same disease?

Takotsubo cardiomyopathy is a phenomenon of transient acute left ventricular dysfunction without obstructive coronary disease seen predominantly in postmenopausal women in the setting of acute emotional or physical stress. Neurocardiogenic injury from acute neurologic events such as intracranial bleeding can precipitate transient left ventricular dysfunction (termed 'neurogenic stunned myocardium') that may be indistinguishable from takotsubo cardiomyopathy. There is controversy about the diagnosis of takotsubo cardiomyopathy in the setting of acute neurologic disorders. We describe a case of a 67-year-old female who initially presented with takotsubo cardiomyopathy due to an acute gastrointestinal illness and 4 years later developed a recurrence in the setting of an ischemic cerebrovascular accident that was associated with more prominent EKG changes and much higher cardiac biomarker release but similar degree of left ventricular dysfunction. This case suggests that susceptibility to this disorder is likely due to patient-specific factors rather than etiology, and acute neurologic disorders should be included as precipitants of takotsubo cardiomyopathy. We also theorize that there may be patients with milder forms of stress-related cardiac injury who do not develop left ventricular dysfunction, being similar to the wide range of cardiac manifestations in patients with acute neurologic disorders. We review published literature on neurologic precipitants of takotsubo cardiomyopathy.     

Tako-Tsubo-like syndrome during anaphylactic reaction

Tako-Tsubo's syndrome (apical ballooning or broken heart syndrome) is a reversible left ventricular dysfunction due to apical asynergy that occurs typically after sudden emotional stress in a subject without coronary disease. It is characterized by acute onset of chest pain or dyspnoea or both and is associated with electrocardiographic changes such as ST segment elevation and/or T wave inversion. Myocardial biomarkers may be normal or slightly elevated. Anaphylaxis is a severe, life-threatening, generalized hypersensitivity reaction, most often starting with urticaria and/or angioedema, that may involve cardiovascular and respiratory systems. Cardiovascular symptoms, including hypotension, cardiac arrhythmia and chest pain, are presumably linked to cardiac mast cell mediator release. We describe the case of a young woman who experienced a profound reversible cardiomyopathy with typical features of Tako-Tsubo's syndrome during an anaphylactic reaction.     

Apical hypertrophic cardiomyopathy mimicking acute coronary syndrome: a case report and review of the literature

Apical hypertrophic cardiomyopathy is a form of hypertrophic cardiomyopathy localized to the left ventricular apex. It is common in Japanese and other Asian populations, where it is generally considered relatively benign. However, its presence has also been recognized, though less commonly, in non-Asian patients. In these patients, the electrocardiographic changes and symptoms associated with apical hypertrophic cardiomyopathy often mimic acute coronary syndromes. Invasive or noninvasive evaluation of the left ventricular cavity confirms the diagnosis, with the "ace-of-spades" sign on left ventriculography being pathognomonic. Its prognosis is relatively benign in terms of cardiovascular mortality; however, morbid sequelae, such as diastolic dysfunction, left atrial enlargement, apical thrombi, ventricular aneurysms, and myocardial infarction, are not uncommon. The authors present a case of apical hypertrophic cardiomyopathy in a Caucasian patient who presented with findings suggestive of acute coronary syndrome and review the literature on apical hypertrophic cardiomyopathy.     

An Unusual Cardiomyopathy after Physical Stress in a Child

Takotsubo cardiomyopathy, or broken heart syndrome, is characterized by transient left ventricular dysfunction associated to chest pain, elevation of cardiac enzymes, and electrocardiographic changes, mimicking an acute coronary syndrome, especially in older women after a physical or emotional stress. It is extremely infrequent in children as well as after infective stress. We described a celiac 4‐year‐old girl, following a gluten‐free diet, who developed features of cardiac failure few days after episodes of acute diarrhea with fever. The patient was treated with oral anticongestive therapy and intravenous immunoglobulins, and she had a dramatic and rapid improvement; echocardiographic features normalized in 48 hours.     

Acute stress-induced cardiomyopathy: a brief observation

Acute stress-induced cardiomyopathy is a syndrome originally described in Japan but increasingly recognized all over the world. Patients typically present with chest pain triggered by an intense emotional or physiological stressor, electrocardiographic changes, and mild cardiac enzyme elevation. Patients typically return to normal cardiac function within 1 month. A retrospective review was conducted of all acute stress-induced cardiomyopathy cases at the University of Maryland Medical Center between May 2006 and May 2007. Six patients fulfilled the criteria and were included in the study. The main clinical features of the syndrome were statistically analyzed. Most patients were post-menopausal women presenting with chest pain. An emotional or physiological stressor was identified in 3 of the 6 patients. Electrocardiographic changes (ST segment elevation or T wave inversion) were present in 3 patients. All patients had left ventricular apical hypokinesis with basal hyperkinesis and elevated cardiac enzymes. The 3 patients receiving a follow up echocardiogram had improved left ventricular contractility and reduced mitral regurgitation within 1 month. Two of the patients had complete resolution in 3-4 days. Stress-induced cardiomyopathy is an important syndrome which mimics an acute myocardial infarction. It is typically self-limiting but can result in ventricular arrhythmias and cardiogenic shock. Our findings should caution clinicians that an identifiable stressor and electrocardiographic changes are not always present. In addition, our observation suggests that patients may regain normal cardiac function in less than 4 days.     

心尖部心肌收缩障碍综合征

心尖部心肌收缩障碍综合征是临床上表现为一过性类似急性心肌梗死样胸痛及心电图改变,冠状动脉造影未见器质性狭窄,左心室造影心尖部收缩功能异常的一类病症。病因尚不清楚,大多在数天至数周恢复正常。     

Acute stress cardiomyopathy

A unique syndrome of heart failure and transient left ventricular systolic dysfunction precipitated by acute emotional or physical stress has recently emerged in the medical literature. The syndrome is referred to by several names, including stress cardiomyopathy, takotsubo cardiomyopathy, left ventricular apical ballooning syndrome, and broken heart syndrome. Because most patients with stress cardiomyopathy present with chest pain, electrocardiographic abnormalities, elevated cardiac enzymes, and focal left ventricular wall motion abnormalities, it is not surprising that for years this syndrome went relatively unrecognized because physicians mistook it for acute myocardial infarction. As reports of this condition have increased worldwide during the past 5 years, it has become clear that stress cardiomyopathy has unique clinical features that can be readily distinguished from those of an acute myocardial infarction. This article reviews the clinical features of stress cardiomyopathy and discusses potential pathophysiologic mechanisms of this disorder.     

Transient apical ballooning: sheep in wolves' garb

Takotsubo cardiomyopathy is a unique acute cardiac syndrome characterized by typical ischemic chest symptoms, an elevated ST segment on the electrocardiogram, and elevated cardiac disease markers. It is often misdiagnosed as acute myocardial infarction. Coronary angiography usually shows no evidence of obstructive atherosclerotic coronary artery disease. Left ventriculography and echocardiography reveal a peculiar regional systolic dysfunction with akinesis of the midventricle and apex and compensatory hyperkinesis of the basal ventricular segments. This syndrome has been shown to have a distinct temporal relationship with intense emotional stressors, and is characterized by an excellent clinical recovery when appropriate conservative measures are taken during the acute phase of the illness. In this review, we highlight the proposed pathophysiology and clinical manifestations of this recognized reversible form of myocardial failure.     

Cardiogenic Shock Complicating Subarachnoid Haemorrhage Diagnosed as Tako Tsubo Cardiomyopathy: A Cautionary Tale

Tako Tsubo or “stress” cardiomyopathy and its variants are well recognised as potential causes of acute coronary presentations, with manifestations including chest pain, cardiac failure and arrhythmia. Similarly, subarachnoid haemorrhage may be associated with cardiac abnormalities. Tako Tsubo cardiomyopathy is a diagnosis of exclusion with typical left ventricular dysfunction in the absence of epicardial coronary disease, but importantly also after exclusion of an intracerebral insult. We describe a case of unrecognised intracerebral haemorrhage with left ventricular dysfunction consistent with both variant Tako Tsubo cardiomyopathy and subarachnoid haemorrhage in a patient treated with intra-aortic balloon pump counterpulsation and associated heparinisation.     

TakoTsubo Cardiomyopathy A Short Review

Takotsubo cardiomyopathy (TCM), otherwise cardiomyopathy,apical ballooning syndrome or broken heart syndrome is a reversible cardiomyopathy, predominantly occurs in post-menopausal women and commonly due to emotional or physical stress. Typically, patients present with chest pain and ST elevation or T wave inversion on their electrocardiogram mimicking acute coronary syndrome, but with normal or non-flow limiting coronary artery disease. Acute dyspnoea, hypotension and even cardiogenic shock may be the presenting feature of this condition. The wall motion abnormalities typically involve akinesia of the apex of the left ventricle with hyperkinesia of the base of the heart. Atypical forms of TCM have also recently been described. An urgent left ventriculogram or echocardiogram is the key investigation to identify this syndrome. Characteristically, there is only a limited release of cardiac enzymes disproportionate to the extent of regional wall motion abnormality. Transient right ventricular dysfunction may occur and is associated with more complications, longer hospitalisation and worse left ventricular systolic dysfunction. Recently, cardiac MRI has been increasingly used to diagnose this condition and to differentiate from acute coronary syndrome in those who have abnormal coronary arteries. Treatment is often supportive, however beta-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocking agent are being used in routine clinical practice. The syndrome is usually spontaneously reversible and cardiovascular function returns to normal after a few weeks. This review article will elaborate on the pathophysiology, clinical features including the variant forms, latest diagnostic tools, management and prognosis of this condition.     

Tako-Tsubo-Kardiomyopathie – eine neue kardiale Entität?

In recent years, a new cardiac syndrome with transient left ventricular dysfunction has been widely reported in Japan. This new entity has been referred to as "tako-tsubo cardiomyopathy" or "apical ballooning", named for the particular shape of the end-systolic left ventricle in ventriculography. This syndrome has also been reported to occur in the western population. The clinical characteristics of this phenomenon have been described as follows: (1) acute onset of reversible left ventricular apical wall motion abnormalities (ballooning) with chest pain, (2) electrocardiographic changes (i.e., ST elevation), (3) minimal myocardial enzymatic release, and (4) no significant stenosis on coronary angiography. Severe emotional or physical stress usually precedes this cardiomyopathy. A unifying mechanistic explanation responsible for this acute but rapidly reversible contractile dysfunction is still lacking. Several investigations suggested catecholamine-mediated cardiotoxicity or coronary artery vasospasm, microvascular injury, an impaired fatty acid metabolism, or transient obstruction of the left ventricular outflow. The optimal treatment of patients presenting with this syndrome may depend on the stage of condition, since various pathophysiological mechanisms underlie the final clinical picture.     

'Tako-Tsubo cardiomyopathy' associated with syndrome malin: reversible left ventricular dysfunction.

A 66-year-old man developed a fever and had a syncopal attack during treatment with imipramine and amantadine for depression and Parkinson's disease. His muscular enzyme levels were very high, so he was diagnosed with incomplete syndrome malin and given hydration therapy. The electrocardiogram recorded an ST segment elevation like acute myocardial infarction in most leads, and the echocardiogram revealed left ventricular dysfunction with severe hypokinesis to dyskinesis of the anterior and apical wall regions, and hyperkinesis of the basal wall. One month from onset, the left ventricular contractility had not changed despite normal coronary arteries. Thallium-201((201)Tl) myocardial scintigraphy showed a perfusion defect and there was no accumulation of iodine-123((123)I) metaiodobenzylguanidine (MIBG) in the entire apex of the heart. Left ventricular function returned to normal and repeat (201)Tl scintigraphy showed recovery by the 4th month. However, there was still an absence of cardiac MIBG uptake. There are a number of reports from Japan of a syndrome demonstrating such reversible left ventricular dysfunction, called 'tako-tsubo cardiomyopathy', but the present case is the first to be associated with syndrome malin. A coronary microvascular abnormality and cardiac sympathetic denervation probably both play an important role in tako-tsubo cardiomyopathy.     

It’s a Trap! Clinical Similarities and Subtle ECG Differences between Takotsubo Cardiomyopathy and Myocardial Infarction

We describe a 65-year-old woman with a history of hypertension and smoking who presented with an acute episode of chest pain precipitated by severe emotional stress. Her initial electrocardiogram done in the emergency room showed non-specific T wave changes in the lateral leads and her cardiac troponin levels were mildly elevated. Because of her clinical presentation, she was admitted with a presumptive diagnosis of acute myocardial infarction and managed with antiplatelet and anticoagulant therapy. Coronary angiogram did not reveal coronary artery disease and left ventriculography showed findings consistent with apical ballooning syndrome or takotsubo cardiomyopathy. Subsequent electrocardiograms displayed dramatic changes including T wave inversions, QT interval prolongation and U waves. The patient remained asymptomatic and recovered uneventfully. Three weeks post-discharge, an echocardiogram documented resolved left ventricular dysfunction. We describe the clinical features and highlight the electrocardiographic findings that may help differentiate takotsubo cardiomyopathy from myocardial infarction.     

Recurrent takotsubo with prolonged QT and torsade de pointes and left ventricular thrombus

Takotsubo cardiomyopathy, also known as “takotsubo syndrome,” refers to transient apical ballooning syndrome, stress cardiomyopathy, or broken heart syndrome and is a recently recognized syndrome typically characterized by transient and reversible left ventricular dysfunction that develops in the setting of acute severe emotional or physical stress. Increased catecholamine levels have been proposed to play a central role in the pathogenesis of the disease, although the specific pathophysiology of this condition remains to be fully determined. At present, there have been very few reports of recurrent takotsubo cardiomyopathy. In this case report, we present a patient with multiple recurrences of takotsubo syndrome triggered by severe emotional stress that presented with recurrent loss of consciousness, QT prolongation, and polymorphic ventricular tachycardia (torsade de pointes) and left ventricular apical thrombus.     

Stress-induced cardiomyopathy (Tako-Tsubo) in a premenopausal woman: A case report from Saudi Arabia

Tako-Tsubo cardiomyopathy (TTC) is a nonischemic cardiomyopathy characterized by reversible left ventricular dysfunction that is seen predominantly in postmenopausal women (>80%). The syndrome has symptoms that are similar to acute myocardial infarction, such as electrocardiogram changes (ST-segment elevation and subsequent giant T wave inversion) and abnormal cardiac enzymes. The clinical prognosis is usually benign. This article reports the first case of a TTC in a premenopausal Saudi woman. Early diagnosis of TTC excludes the use of stents, thrombolytics, and long-term coronary heart disease medications.     

Takotsubo cardiomyopathy: an acute and reversible cardiomyopathy mimicking acute myocardial infarction

Takotsubo cardiomyopathy is an acute, reversible form of left ventricular dysfunction precipitated by emotional or physical stress. The condition is important to recognise as it mimics acute myocardial infarction and acute coronary syndrome. Most patients are female and postmenopausal. Presenting symptoms include severe chest pain, acute dyspnoea, hypotension or even cardiogenic shock. The ECG changes are suggestive of an acute coronary syndrome with T-wave inversion with/without ST elevation, most often in the precordial leads. The syndrome is characterised by a sudden onset of transient extensive akinesia of the left ventricle, often involving all three major coronary artery territories, in the absence of significant coronary artery stenosis. The wall motion typically involves the apex of the left ventricle with hyperkinesis of the base of the heart. Variant forms have recently been described where the wall motion abnormality involves the mid-ventricular wall with hyperkinesis of the base and apex, or the base of the heart with hyperkinesis of the apex. Characteristically, there is only a limited release of cardiac enzymes disproportionate to the extent of regional wall motion abnormality. Transient right ventricular dysfunction may occur and is associated with more complications, longer hospitalisation and worse left ventricular systolic dysfunction. Serial echocardiography is useful to document improvement in cardiac function. The pathogenesis is unclear. Transient mid-cavity obstruction has been invoked with subsequent myocardial stunning in the akinetic segments. Treatment is supportive. The most effective long-term management remains to be defined. Although the prognosis is good with recovery of ventricular function at about three weeks, some patients have died. The syndrome may recur.     

Diabetic cardiomyopathy: concept,heart function,and pathogenesis

The diabetic cardiomyopathy is a disease caused by diabetes and is characterised by the presence of diastolic and/or systolic left ventricular dysfunction. Diabetes may produce metabolic alterations, interstitial fibrosis, myocellular hypertrophy, microvascular disease and autonomic dysfunction. It is thought that all of them may cause cardiomyopathy. Other abnormalities that are usually associated with diabetes such as hypertension, coronary artery disease and nephropathy should be excluded before diagnosing diabetic cardiomyopathy. There is no evidence that diabetic cardiomyopathy alone can produce heart failure. However, subclinical ventricular dysfunction has been described in young asymptomatic diabetic patients without other diseases that could affect the cardiac muscle. In these cases we should consider that diabetes is the only cause of the myocardial disease. More studies are needed to know the natural history of diabetic cardiomyopathy.     

Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy

Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.