Transient mid-ventricular ballooning cardiomyopathy: a new entity of Takotsubo cardiomyopathy

We present a case of a 64-year-old man with transient mid-ventricular ballooning cardiomyopathy. Left ventriculography showed morphological differences with ballooning around the whole mid-portion of the left ventricle, although precipitating factors and clinical courses were similar to Takotsubo cardiomyopathy. We suspect that transient mid-ventricular ballooning cardiomyopathy is a new pathological entity in Takotsubo cardiomyopathy.     

Recurrent episodes of takotsubo-like transient left ventricular ballooning occurring in different regions: a case report

A 62-year-old male with emphysema developed recurrent episodes of transient left ventricular ballooning occurring in different regions. Left ventriculography revealed symmetric mid-ventricular ballooning when he was 60 years old, and he also developed mid-ventricular ballooning of larger extent at the age of 62 years. Furthermore, as he was treated for severe asthma attack 3 months later, left ventricular apical ballooning occurred. Echocardiography also demonstrated akinetic wall motion in the right ventricular apex. These episodes showed myocardial infarction-like onset, ST elevations on electrocardiography, no significant increases in cardiac enzymes, wall motion abnormalities incompatible with coronary artery disease, and complete recovery within a few weeks. From these findings, we speculate that the recurrent left ventricular wall motion abnormalities including the mid-ventricular ballooning were so-called takotsubo-like left ventricular dysfunction.     

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.     

A rare case of tako-tsubo cardiomyopathy with variable forms of left ventricular dysfunction: a new entity

We report a rare case of an 83-year-old woman with tako-tsubo cardiomyopathy, who presented with variable forms of left ventricular dysfunction during her clinical course. The distribution regional wall-motion abnormalities of the left ventricle on echocardiography had changed from a mid-ventricular ballooning type to the apical ballooning type 3 days from the onset. We suggest that these findings may indicate a new or variant entity of tako-tsubo cardiomyopathy.     

Inverted Tako-Tsubo cardiomyopathy associated with bronchoalveolar lavage

Tako-Tsubo cardiomyopathy (TTC), also known as transient left ventricular (LV) ballooning syndrome or stress-induced cardiomyopathy, is characterised by transient LV dysfunction in the absence of significant angiographic coronary stenoses, frequently provoked by an episode of emotional or physical stress. In TTC, typically transient akinesis or dyskinesis of the LV apical segments with normal or hypercontractile basal wall motions is observed. Recently, several cases of atypical or inverted transient TTC sparing the LV apex have been reported. We report a case of inverted TTC showing akinesis of the basal and mid-ventricular segments of the LV with apical hyperkinesia triggered by bronchoscopy with bronchoalveolar lavage.     

Mid-ventricular ballooning heart syndrome

Stress cardiomyopathies have been increasingly reported these last years, especially in women as a transient left ventricular apical ballooning syndrome. We report six cases in whom, in the context of anxious situations, echocardiograms and ventriculographies revealed mid-ventricular akinesis with preservation of apical and basal contractilities with normal coronary arteriography. This "mid-ventricular ballooning heart syndrome " should probably be classified as a new type of heart stress related syndrome.     

Takotsubo cardiomyopathy--a new variant and widening disease spectrum

Classic takotsubo cardiomyopathy had left ventricular apical ballooning. Variants with mid-ventricular ballooning without involvement of the apex have been described. We describe a new variant of takotsubo cardiomyopathy where apical contraction was preserved while the rest of the ventricle was dyskinetic.     

The three faces of takotsubo cardiomyopathy in a single patient

While the classical apical ballooning takotsubo cardiomyopathy (TC) was first reported in the 1990s, the rarer mid-ventricular and basal variants were not formally recognized until recently and they remain poorly understood. In this case report, we describe a 67-year-old woman who, during her hospitalization for a subarachnoid hemorrhage and subsequent readmission, experienced multiple complications, each of which resulted in a different variant of TC. To our knowledge, this is the first report of a single patient developing all three variants of TC.     

Pheochromocytoma crisis presenting with shock and tako-tsubo-like cardiomyopathy

Pheochromocytoma usually presents with hypertension but it may also be an unusual aetiology of cardiogenic shock in order to catecholamine induced myocardial dysfunction. We report the devastating course of a patient with tako-tsubo like apical cardiomyopathy during pheocytoma crisis who presented with classical transient left ventricular apical ballooning 6 months before.     

Isolated left ventricular basal ballooning phenotype of transient cardiomyopathy in young women

This report describes a variant of transient regional left ventricular dysfunction in which isolated basal left ventricular akinesia with normal mid-ventricular (papillary-level) wall motion and apical hypercontractility were noted in young women (mean age 31 years). This finding was demonstrated in 3 consecutive patients; the first patient was experiencing emotional life-altering events, and the second presented with an acute flare of multiple sclerosis. The third patient presented < 24 hours after methamphetamine use. Coronary angiography demonstrated normal epicardial coronary arteries in all patients. Wall motion abnormalities resolved within 2 to 6 weeks. In conclusion, the entity described in this report is reminiscent of apical ballooning ("Tako-Tsubo"), mid-ventricular ballooning, and apical sparing syndromes; however, isolated basal left ventricular involvement has not been previously described and is a newer variant in the spectrum of transient cardiomyopathies. The pathophysiology of this entity has not been elucidated. A unifying feature between the transient cardiomyopathic syndromes most likely is in the concentration, distribution, and activity of cardiac adrenergic receptors.     

Percutaneous septal ablation for hypertrophic cardiomyopathy and mid-ventricular obstruction.

AIMS: Percutaneous transluminal septal myocardial ablation by alcohol-induced septal branch occlusion is a new treatment option in symptomatic patients with hypertrophic cardiomyopathy and subaortic, SAM-associated obstruction. We report on a patient with mid-ventricular obstruction and echocardiographic-guided reduction of septal hypertrophy. METHODS AND RESULTS: A 52-year-old woman with NYHA class III and recurrent exercise-induced syncope suffered from hypertrophic cardiomyopathy with mid-ventricular obstruction. She had a systolic gradient of 71 mmHg at rest and 153 mmHg post-extrasystole, and diastolic inflow gradient of 20 mmHg. Echo-guided percutaneous transluminal septal myocardial ablation with occlusion of the fourth septal branch resulted in acute reduction and final elimination of systolic, as well as diastolic resting and provocable gradients. Complications were not seen. At 3 months' follow-up the patient was asymptomatic and without further syncopes. CONCLUSIONS: Echocardiographic-guided percutaneous transluminal septal myocardial ablation is able to reduce gradients in hypertrophic cardiomyopathy and mid-ventricular obstruction with consecutive improvement of symptoms.     

Atypical form of left ventricular ballooning after a violent attack

The syndrome of "apical ballooning" is characterized by an acute onset of transient akinesia of the apical portion of the left ventricle accompanied by electrocardiographic changes and minimal myocardial enzymatic release mimicking acute myocardial infarction without significant stenosis on the coronary angiogram. Emotional or physical stress might trigger this reversible form of cardiomyopathy. We describe a case of a 70-year old woman presenting with an atypical form of ventricular ballooning after a violent attack.     

Could left ventricular apical ballooning represent spontaneous myocardial infarction abortion?

Left ventricular apical ballooning, also named tako-tsubo cardiomyopathy, is a syndrome characterized by chest pain, transient left ventricular dysfunction and specific electrocardiographic changes mimicking an acute myocardial infarction without significant stenosis on the coronary angiogram. Although the aetiology remains unknown, several reports have found that preceding psychological stress could act as a trigger. This report describes a case of tako-tsubo-like left ventricular apical ballooning in a patient with "soft" atherosclerotic plaque at the middle portion of the left anterior descending coronary artery.     

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.     

Acute subarachnoid haemorrhage as a precipitant for takotsubo cardiomyopathy: a case report and discussion

Takotsubo cardiomyopathy is a recently recognised acute cardiac entity. It involves transient left ventricular apical ballooning, which is usually preceded by an episode of physiological or emotional stress. Its presentation may mimic acute myocardial infarction but there is no evidence of obstructive disease at coronary angiography. The aetiology of this condition has not been clearly defined, though a number of hypotheses have been put forward. Precipitating factors vary widely, including acute medical conditions and emotional stressors. We present a case of takotsubo cardiomyopathy precipitated by acute subarachnoid haemorrhage, the first report of this association in a Caucasian patient, and discuss the implications for clinicians involved in the management of such a case.     

Tako-Tsubo cardiomyopathy: new insights into the possible underlying pathophysiology.

Tako-Tsubo cardiomyopathy is characterised by an atypical distribution of left ventricular (LV) dysynergy with apical ballooning and compensatory basal hyperkinesis. Coronary angiography is normal. Several substrates have been put forward to explain the underlying pathophysiology such as raised catecholamine levels (due to physical or emotional stress), multivessel epicardial coronary spasm or diffuse microvascular spasm. However, the pathophysiology has not yet been fully clarified. We present a series of cases whose findings could explain the mechanism underlying this syndrome. Four consecutives patients, all female, were admitted with the clinical features typical of Tako-Tsubo syndrome. In all, severe widespread transient LV mid-apical a/dyskinesia was associated with a mid-cavity dynamic obstruction which resolved prior to the resolution of the LV wall motion abnormalities. In all cases the dynamic LV obstruction was related to localised mid-ventricular septal thickening. After improvement in wall motion, a low-dose strain/strain rate dobutamine stress-echocardiography (DSE) was performed to determine the underlying ischaemic substrate. This provoked an LV mid-cavity gradient at peak dose in all. Regional deformation changes during DSE showed the affected myocardium to have the typical response diagnostic of regional stunning. CONCLUSION: We postulate that an important unrecognised factor in the development of Tako-Tsubo cardiomyopathy is the presence of abnormal myocardial functional architecture (such as localised mid-ventricular septal thickening), which in the presence of dehydration and/or raised catecholamine levels due to physical or emotional stress, leads the development of a severe transient LV mid-cavity obstruction. This effectively sub-divides the LV into two functionally different chambers with a marked increase in wall stress in the high pressure distal apical chamber. This, in combination with the abnormal high circulating catecholamine levels, induces widespread sub-endocardial ischaemia which is unrelated to a specific coronary artery territory. With rehydration/fall in catecholamine levels the interventricular gradient resolves and distal function recovers. Low dose SR/S DSE confirms that the distal ischaemic substrate is myocardial stunning.     

Diverse clinical spectrum of stress-induced cardiomyopathy

Stress-induced cardiomyopathy or Takotsubo cardiomyopathy is an uncommon disorder characterized by apical ballooning. The etiology and pathophysiology of this syndrome has not been fully evaluated. This case series examined the clinical characteristics and outcomes of 10 patients with confirmed stress-induced cardiomyopathy. We identified 10 cases of stress-induced cardiomyopathy. All exhibit characteristic apical ballooning and basal hyperkinesia except one with an "inverted Takotsubo" pattern. Coronary angiography excluded coronary artery stenoses as a cause of cardiomyopathy. Patient characteristics, cardiac function, follow-up echocardiography and outcomes were determined. 60% of cases were female and 70% of cases had ST-segment elevations. Identified precipitants included severe emotional stress, subarachnoid haemorrhage and sepsis. None of the cases had angiographically significant coronary stenosis. One patient had an "inverted Takotsubo" pattern with mid-ventricular ballooning. Stress-induced cardiomyopathy is a clinical spectrum which can present with a classical "Takotsubo" or "inverted Takotsubo" pattern. Presentation is varied but characterized by recovery to normal cardiac systolic function. Study of this syndrome may enhance further understanding of the "brain-heart" relationship.     

Tako-tsubo cardiomyopathy: a rare and badly known clinical entity

Tako-tsubo cardiomyopathy or "transient left ventricular (LV) apical ballooning" clinically presents like acute myocardial infarction without angiographic stenosis on coronary angiogram and a transient (reversible) LV apical ballooning. We discuss here about a 56-year-old woman complains of first constrictive chest pain with ST elevation in leads V2-V6 and minimal enzymatic release. Coronary angiogram demonstrates vessels without stenosis and the left ventriculogram an extensive LV apical wall motion abnormalities. LV dysfunction will only be transient since 24 hours after admission echographic images demonstrate quite complete recovery of LV systolic function. The pain disappears 12 hours after admission and the creatine kinase level normalize after 48 hours.     

Transient left ventricular ballooning (tako-tsubo cardiomyopathy) soon after intravenous ergonovine injection following caesarean delivery

Transient left ventricular ballooning also called tako-tsubo syndrome, is increasingly being recognized as cardiomyopathy mimicking the clinical scenario of an acute myocardial infarction. Generally, it is characterized by apical ballooning appearance of the left ventricle in the presence of normal coronary arteries on the angiogram. Recently, a variant form involving the midventricle with sparing of the apical and basal segments has been described. This syndrome is more prevalent in postmenopausal woman and usually preceded by extreme emotional and/or physical stress. We describe a case never reported before of transient left ventricular ballooning occurring during the early postpartum period after ergonovine injection rapidly evolving from a 'typical apical' ballooning into a 'midventricular' myocardial dysfunction.     

Tako-tsubo-like syndrome without emotional stress: a case report]

The tako-tsubo-like syndrome (also named left ventricular apical ballooning) is an unusual cardiomyopathy with a high incidence in the Japanese female population, following an emotional stress. The clinical features (typical chest pain), electrocardiographic (negative T wave and persistent ST-segment elevation in anterior leads), echocardiographic (transient left ventricular apical dysfunction with hyperkinesis of basal segments) are suggestive of an acute anterior myocardial infarction; nevertheless all reports in the literature show coronary arteries without angiographic lesions. We report the case of a 77-year-old female (without cardiovascular risk factors) with two prior episodes of paroxysmal atrial fibrillation, who arrived to the emergency department with chest pain, electrocardiographic and echocardiographic features, suggestive of an acute anterior myocardial infarction, not preceded by any emotional stress. Coronary angiography showed coronary arteries without atherosclerotic lesions; left ventriculography showed an anteroapical dysfunction. The follow-up performed with transthoracic echocardiography (2 months later) showed complete regression of regional wall motion abnormalities. The pathophysiological determinant seems to be related to the release of catecholamines (such as epinephrine and norepinephrine) able to create a transient board of ischemic cardiomyopathy through a direct cellular damage.