Ventricular outflow tract obstruction, systolic anterior motion and acute mitral regurgitation in Tako-Tsubo syndrome

Tako-Tsubo syndrome is characterized by ECG changes mimicking acute myocardial infarction, left ventricular wall motion abnormalities in the apical region with preserved function of base, and normal coronary arteries. We report the cases of two old women, presenting apical akinesis, basal hyperkinesis, severe systolic dysfunction and severe mitral regurgitation (MR). Doppler echocardiography showed a left ventricular outflow tract obstruction (LVOTO), systolic anterior motion (SAM) of the mitral valve anterior leaflet. The patients recovered and, early later, left ventricular ejection fraction was documented as normal at echocardiography. The contemporary presence of LVOTO, SAM and MR might explain worsening of heart failure or incidence of cardiogenic shock in some patients with Tako-Tsubo syndrome.     

Haemodynamic effects of acute intravenous metoprolol in apical ballooning syndrome with dynamic left ventricular outflow tract obstruction

Takotsubo syndrome, also called apical ballooning syndrome, is a clinical entity characterized by transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid‐segments with or without apical involvement, and without obstructive coronary lesions. The contemporary presence of left ventricular outflow tract obstruction (LVOTO), systolic anterior motion of the anterior mitral leaflet, and acute mitral regurgitation might explain the worsening of the heart failure or the occurrence of cardiogenic shock in some patients with apical ballooning syndrome. The use of β‐blockers should improve the LVOTO gradient by reducing basal hypercontractility, increasing left ventricular filling and size, and reducing heart rate. However, clear evidence of the direct haemodynamic effects of β‐blockers is still lacking. We present a case of apical ballooning syndrome complicated by dynamic LVOTO, treated with metoprolol.     

SAM not only in hypertrophic cardiomyopathy

Hypertrophic obstructive cardiomyopathy with significant hypertrophy of the basal septum is the most frequently reported cause of left ventricular outflow tract obstruction (LVOTO) in the mechanism of systolic anterior movement (SAM). Additionally, other conditions such as dehydration, vasodilatation, mitral valve repair, dobutamine stress echocardiography and pheochromocytoma have been associated with LVOTO. In this report, we present a case of a patient without hypertrophic cardiomyopathy who developed severe LVOTO in the SAM mechanism. The presented case serves as a reminder that hypovolaemia together with hyperdynamic state resulting from increased catecholemines may result in the development of dynamic LVOTO.     

Stress (Takotsubo) cardiomyopathy--a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning

Stress cardiomyopathy, also referred to as Takotsubo cardiomyopathy, is an increasingly recognized clinical syndrome characterized by acute reversible apical ventricular dysfunction. We hypothesize that stress cardiomyopathy is a form of myocardial stunning, but with different cellular mechanisms to those seen during transient episodes of ischemia secondary to coronary stenoses. In this syndrome, we believe that high levels of circulating epinephrine trigger a switch in intracellular signal trafficking in ventricular cardiomyocytes, from G(s) protein to G(i) protein signaling via the beta(2)-adrenoceptor. Although this switch to beta(2)-adrenoceptor-G(i) protein signaling protects against the proapoptotic effects of intense activation of beta(1)-adrenoceptors, it is also negatively inotropic. This effect is greatest at the apical myocardium, in which the beta-adrenoceptor density is greatest. Our hypothesis has implications for the use of drugs or devices in the treatment of patients with stress cardiomyopathy.     

Prevalence of stress-induced myocardial stunning (Tako-Tsubo cardiomyopathy) among patients undergoing emergency coronary angiography for suspected acute myocardial infarction

Stress-induced myocardial stunning is defined as a syndrome of acute chest pain, ST-T changes on the ECG and transient left ventricular apical wall motion abnormalities mimicking acute myocardial infarction but with surprisingly normal coronary angiography findings.

The aim of this retrospective study is to assess the prevalence of stress-induced myocardial stunning among patients undergoing urgent coronary angiography for suspected acute myocardial infarction.

During a four-year period (2002–2005), a total of 5876 patients underwent urgent coronary angiography for suspected acute myocardial infarction at three tertiary centers. Four patients fulfilled the diagnostic criteria for stress-induced myocardial stunning. Thus, the cath-lab prevalence of stress-induced myocardial stunning (i.e. among patients undergoing urgent coronary angiography for suspected acute myocardial infarction) was estimated as 1 per 1469 ST-elevation coronary angiograms (i.e. 0.07%) The estimated annual population incidence of this rare disorder was calculated as 0.00006%.

Stress-induced myocardial stunning is an extremely rare syndrome among patients undergoing emergency coronary angiography for suspected acute myocardial infarction.     

Ampulla cardiomyopathy with delayed recovery of microvascular stunning: a case report

A 71-year old woman with schizophrenia was admitted to our hospital on November 26, 2002 under a diagnosis of acute myocardial infarction because of ST segment elevation in leads V2-V5 and positive serum cardiac troponin T level. Emergent coronary angiography showed no significant stenosis, but left ventriculography demonstrated apical ballooning and basal hyperkinesis. The final diagnosis was ampulla cardiomyopathy. Myocardial contrast echocardiography during the acute phase revealed an echocontrast defect consistent with the area of apical ballooning. The condition improved gradually as determined by disappearance of the abnormal wall motion. The coronary flow reserve in the left anterior descending artery measured by transthoracic Doppler echocardiography was decreased at 1.5 in the acute phase and gradually recovered over a period of 3 months (23 days, 1.9; 96 days, 2.9). Microvascular stunning defined as decreased coronary flow reserve was observed and recovery was delayed in this case compared with cases of myocardial stunning. These findings are of interest in evaluating the pathophysiology of ampulla cardiomyopathy.     

Acute Mitral Regurgitation in Suspected Acute Coronary Syndrome: What Is the Cause?

Patients presenting with acute chest pain and suspected acute coronary syndrome (ACS) who have nonobstructive coronary disease on angiography, but new regional wall motion abnormalities are often diagnosed with takotsubo cardiomyopathy (TTC). The cause of TTC is often physical or emotional stress, and this clinical syndrome occurs more often in women than men. When hemodynamically significant mitral regurgitation (MR) accompanies TTC, the mechanism must be carefully elucidated, as systolic anterior motion (SAM) of the mitral valve can cause significant MR and left ventricular outflow tract (LVOT) obstruction. These patients can be conservatively managed, with SAM‐associated MR and LVOT obstruction resolving with medical therapy as TTC‐associated left ventricular (LV) dysfunction resolves, as opposed to true ACS where further intervention for MR is often necessary. This case report describes 2 cases of TTC presenting with severe MR, who were initially thought to have ACS‐associated MR caused by ischemia, but on further echocardiographic interrogation were found to have SAM‐associated MR which resolved along with resolution of LV wall motion abnormalities on medical therapy by follow‐up echocardiography.     

Transient left apical ballooning syndrome--the need for a common terminology? A reply

The apical ballooning syndrome, called also transient left ventricular apical ballooning syndrome or Tako-tsubo cardiomyopathy is a new syndrome that mimics acute myocardial infarction. The authors comment the statement of Dr Parodi who recommended a new denomination of neuromediated myocardial stunning. According to many different denominations of the syndrome and over 25 years history of research on it, the authors recommended a name of "transient left ventricular ballooning syndrome (TLVBS)" and pursued to goal a new expert consensus.     

Myocardial Stunning Following Combined Modality Combretastatin‐Based Chemotherapy: Two Case Reports and Review of the Literature

Myocardial stunning, known as stress cardiomyopathy, broken‐heart syndrome, transient left ventricular apical ballooning, and Takotsubo cardiomyopathy, has been reported after many extracardiac stressors, but not following chemotherapy. We report 2 cases with characteristic electrocardiographic and echocardiographic features following combined modality therapy with combretastatin, a vascular‐disrupting agent being studied for treatment of anaplastic thyroid cancer. In 1 patient, an ECG performed per protocol 18 hours after drug initiation showed deep, symmetric T‐wave inversions in limb leads I and aVL and precordial leads V₂ through V₆. Echocardiography showed mildly reduced overall left ventricular systolic function with akinesis of the entire apex. The patient had mild elevations of troponin I. Coronary angiography revealed no epicardial coronary artery disease. The electrocardiographic and echocardiographic abnormalities resolved after several weeks. The patient remains stable from a cardiovascular standpoint and has not had a recurrence during follow‐up. An electrocardiogram performed per protocol in a second patient showed deep, symmetric T‐wave inversions throughout the precordial leads and a prolonged QT interval. Echocardiography showed mildly reduced left ventricular function with hypokinesis of the apical‐septal wall. Acute coronary syndrome was ruled out, and both the electrocardiographic and echocardiographic changes resolved at follow‐up. Although the patient remained pain‐free without recurrence of anginal symptoms during long‐term follow‐up, the patient developed progressive malignancy and died. Copyright © 2009 Wiley Periodicals, Inc.     

Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction

Apical ballooning syndrome (ABS) is a unique reversible cardiomyopathy that is frequently precipitated by a stressful event and has a clinical presentation that is indistinguishable from a myocardial infarction. We review the best evidence regarding the pathophysiology, clinical features, investigation, and management of ABS. The incidence of ABS is estimated to be 1% to 2% of patients presenting with an acute myocardial infarction. The pathophysiology remains unknown, but catecholamine mediated myocardial stunning is the most favored explanation. Chest pain and dyspnea are the typical presenting symptoms. Transient ST elevation may be present on the electrocardiogram, and a small rise in cardiac troponin T is invariable. Typically, there is hypokinesis or akinesis of the mid and apical segments of the left ventricle with sparing of the basal systolic function without obstructive coronary lesions. Supportive treatment leads to spontaneous rapid recovery in nearly all patients. The prognosis is excellent, and a recurrence occurs in <10% of patients. Apical ballooning syndrome should be included in the differential diagnosis of patients with an apparent acute coronary syndrome with left ventricular regional wall motion abnormality and absence of obstructive coronary artery disease, especially in the setting of a stressful trigger.     

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is characterized by transient left ventricular apical wall motion abnormalities, chest pain with electrocardiographic changes, and modest myocardial enzymatic release mimicking acute coronary syndrome, but without significant coronary artery disease. TC is an increasingly recognized type of acquired cardiomyopathy occurring commonly after a recent stressful event, in particular emotional stress, and is relatively common in middle-aged and older women. The pathogenetic mechanism remains unknown. Catecholamine surge related to emotional distress seems to play a major role in the pathogenesis of this cardiomyopathy, rendering TC a type of neurocardiological disorder that manifests as acute but reversible heart failure. Clinicians should consider this syndrome in the differential diagnosis of patients presenting with clinical findings suggestive of acute coronary syndrome, especially in postmenopausal women with a recent history of acute emotional or physical stress.     

Reversible T‐Wave Inversions and Neurogenic Myocardial Stunning in a Patient with Recurrent Stress‐Induced Cardiomyopathy

A 72‐year‐old female was diagnosed as a stress‐induced cardiomyopathy from apical ballooning pattern of left ventricular dysfunction without coronary artery stenosis after the mental stress. ECG showed the transient T‐wave inversions after the ST‐segment elevations. By the mental stress after 1 year, she showed a transient dysfunction with similar ECG changes again. T‐wave inversions recovered earlier, and cardiac sympathetic dysfunction showed a lighter response corresponding to the less severe dysfunction than those after the first onset. Wellens’ ECG pattern was associated with the degree of neurogenic myocardial stunning with sympathetic hyperinnervation caused by mental stress.     

Systolic anterior motion of the mitral valve in tako-tsubo cardiomyopathy: Still a matter of debate?

We present a case which developed a typical tako-tsubo-like cardiomyopathy (TTC) during dobutamine stress echocardiography (DSE). Its originality is related to several findings, which have never been described simultaneously in the same patient. This 63-year-old woman with normal coronary angiography and no evidence of coronary vasospasm had a biphasic response to DSE, a finding which usually occurs in coronary artery disease. Moreover, the symmetric extensive wall motion abnormalities (WMA) occurred simultaneously with the development of a systolic anterior motion of the mitral valve (SAM) and left ventricular obstruction, and was clinically asymptomatic. Although in TTC the stunning usually occurs for several days, WMA and SAM resolved within few minutes after cessation of dobutamine and administration of a beta-blocker. And finally, exercise echo performed at the same target heart rate few days later did not induce neither a SAM nor WMA, which suggests that left ventricular obstruction could have played a role in the pathogenesis of this case by supply-demand mismatch. Concomitant coronary microvascular dysfunction was also demonstrated by a reduction of the non-invasive coronary flow reserve in the distal part of the left anterior descending artery.     

Reversible left ventricular dysfunction "takotsubo" cardiomyopathy associated with hyperthyroidism

Myocardial stunning with hyperthyroidism is rare. A 79-year old woman with hyperthyroidism was admitted to our hospital complaining of palpitations due to paroxysmal atrial fibrillation. An echocardiogram showed akinesis of the apical wall which was not observed 2 weeks before admission. Cardiac catheterization performed in the acute phase showed normal coronary arteries and no evidence of provocative spasms. The wall motion abnormality disappeared entirely after 1 week in hospital. We report a case of transient left ventricular dysfunction, so called "takotsubo" cardiomyopathy, associated with hyperthyroidism.     

Takotsubo cardiomyopathy presenting as multivessel coronary spasm syndrome: case report and review of the literature

Takotsubo' cardiomyopathy, more recently called transient left ventricular apical ballooning syndrome, is a recently described acute cardiac syndrome. This increasingly reported syndrome consists of an acute onset of transient extensive akinesia of the apical and mid-portions of the left ventricle, producing ballooning of the apex in systole in the absence of significant coronary artery disease. The syndrome is accompanied by angina-like chest pain, electrocardiographic changes and minimal release of cardiac enzymes and biomarker levels, mimicking an acute myocardial infarction and is often preceded by an episode of emotional or physical stress, which may play a key role in the pathogenesis of the disorder. However, the exact mechanism still remains unknown. We describe the history of an 83-year-old man presenting to the emergency department with clinical findings of acute myocardial infarction with ST-segment elevation in the precordial leads, but emergency coronarography showed no significant obstruction. Left ventricular angiography demonstrated the typical apical ballooning. ST-segment elevation in the precordial leads on the admission ECG resolved the day after, but new anginal chest pain was accompanied by transient ST-segment elevation in the inferior leads, suggesting multivessel coronary spasm. Awareness of the existence of the syndrome is important and should be considered in the differential diagnosis of patients presenting with an acute coronary syndrome.     

Noninvasive detection of Takotsubo [corrected] cardiomyopathy using multi-detector row computed tomography

We present a 60-year-old woman with chest pain preceded by emotional stress. Trans-thoracic echocardiography demonstrated localized left ventricular hypokinesis around the apical area. Multi-detector row computed tomography (MDCT) revealed no significant stenosis in the coronary arteries, which comfirmed Takotsubo-like cardiomyopathy. We show here the usefulness of MDCT for the noninvasive differentiation of Takotsubo cardiomyopathy from acute coronary syndrome.     

The Tako-Tsubo syndrome: no evidence of peripheral endothelial or microvascular dysfunction

Takotsubo cardiomyopathy is recently defined reversible left ventricular dysfunction and apical ballooning resembling acute myocardial infarction. Although electrocardiographic, echocardiographic, biochemical and clinical findings indicate a possible acute coronary syndrome, coronary angiography reveals normal epicardial coronary arteries without any obstructing lesion. Here we describe a 52 year old woman admitted with chest pain and ST elevation with mildly increased cardiac enzymes. She was diagnosed as Takotsubo cardiomyopathy after 1 week of hospital stay and evaluation.     

Transient mid-ventricular ballooning syndrome complicated by syncope: a variant of tako-tsubo cardiomyopathy

Tako-tsubo cardiomyopathy, also called transient left ventricular apical ballooning, is a clinical entity first described in Japan. This syndrome is triggered by emotional or physical stress and mimics an acute coronary syndrome, although the coronary arteries are essentially normal. Recently, several reports have described variant forms of tako-tsubo cardiomyopathy, such as inverted tako-tsubo and mid-ventricular ballooning cardiomyopathy. We describe a case herein of an 87-year-old woman who presented a variant form of tako-tsubo cardiomyopathy complicated by syncope. Our findings may contribute to an elucidation of the mechanism underlying tako-tsubo cardiomyopathy.     

Echocardiographic predictors of left ventricular outflow tract obstruction and systolic anterior motion of the mitral valve after mitral valve reconstruction for myxomatous valve disease

OBJECTIVE

To determine predictors of systolic anterior motion and left ventricular outflow tract obstruction (SAM/LVOTO) after mitral valve repair (MVRep) in patients with myxomatous mitral valve disease.

BACKGROUND

Mechanisms for the development of SAM/LVOTO after MVRep have been described; however, predictors of this complication have not been explored. We hypothesize that pre-MVRep transesophageal echocardiography (TEE) can predict postrepair SAM/LVOTO.

METHODS

Using TEE, the lengths of the coapted anterior (AL) and posterior (PL) leaflets and the distance from the coaptation point to the septum (C-Sept) were measured before and after MVRep in 33 patients, including 11 who developed SAM/LVOTO (Group 1) and 22 who did not (Group 2).

RESULTS

Group 1 patients had smaller AL/PL ratios (0.99 vs. 1.95, p < 0.0001) and C-Sept distances (2.53 vs. 3.01 cm, p = 0.012) prior to MVRep than those in Group 2. Resolution of SAM/LVOTO was associated with increases in AL/PL ratio and C-Sept distance. This reflects a more anterior position of the coaptation point in those who developed SAM/LVOTO.

CONCLUSIONS

These data suggest that TEE analysis of the mitral apparatus can identify patients likely to develop SAM/LVOTO after MVRep for myxomatous valve disease. The findings are consistent with the concept that SAM of mitral leaflets is due to anterior malposition of slack mitral leaflet portions into the LVOT. The position of the coaptation point of the mitral leaflets is dynamic and a potential target and end point for surgical designs to prevent SAM/LVOTO post MVRep.     

MitraClip‐induced systolic anterior motion complicated by pericardial effusion: A case report

Systolic anterior motion (SAM) of the anterior mitral leaflet is a well reported complication of surgical mitral valve repair (MVR). In the current report, we present a case of SAM with left ventricular outflow tract obstruction (LVOTO) which occurred after transcatheter mitral valve repair (TMVR) using the MitraClip device. LVOTO was caused by the combination of protrusion of the MitraClip device into the LVOT and underfilling of the left ventricle due to pericardial effusion and atrial fibrillation. Rapid clinical resolution and marked decline in LVOT pressure gradient occurred following surgical drainage and windowing of the pericardium. We conclude that SAM and LVOTO could occur after TMVR. Seeking and addressing reversible aggravators of LVOTO including pericardial effusion is essential and could potentially make the difference between a successful procedure and a failed one. © 2016 Wiley Periodicals, Inc.