Transient left ventricular apical ballooning during dobutamine myocardial perfusion imaging

The transient left ventricular apical ballooning is characterized by wall motion abnormalities involving the apex in the absence of obstructive coronary disease. It is precipitated by acute emotional or physical stress and is most often reported in post-menopausal women. We report a case of transient left ventricular "apical ballooning" without significant coronary artery disease precipitated by high dose dobutamine infusion during pharmacological stress myocardial perfusion imaging. The unique feature of our case was precipitation by chemical stress rather than emotional/physical stress.     

Stress-induced transient left ventricular apical ballooning]

Transient left ventricular apical ballooning is a quite rare clinical event mostly described in the Japanese population. It is also known as tako-tsubo-like syndrome due to the peculiar shape on endsystolic left ventriculogram which is like a tako-tsubo, an ancient device used for trapping octopuses in the Japanese sea. The clinical features of this cardiomyopathy, which mimicked an acute coronary syndrome in an Italian 78-year-old man, are described. Acute left ventricular dysfunction with the typical left ventriculogram and normal epicardial coronary arteries followed an acute emotional and physical stress: the patient felt off his boat, while lifted well up above the water of a great Italian lake during routinary servicing, with consequent chest and head traumas. The combination of emotional and physical stress with the dive in the lake cold water could have caused a brisk and marked increase in catecholamines with possible direct myocardial injury. The occurrence of a rare case of a Japanese cardiomyopathy, also mentioned by a device used in sea-fishing, in an Italian patient following an accidental dive in a lake, appears at least peculiar.     

Clinical features of transient left ventricular apical ballooning

This report describes the clinical characteristics of 8 consecutive patients with transient left ventricular apical ballooning identified among 389 patients (2%) admitted to a tertiary referral hospital with suspected acute coronary syndromes over a 1-year period. Among these patients, 2 cases appeared to be caused by acute myocarditis and 1 case by head trauma with intracranial bleeding. In the remaining 5 cases, no apparent cause was found. All patients but 1 were postmenopausal women (mean age 60 +/- 13.5 years). Preceding strong emotional or physical stress was present in 6 patients. The presenting symptom in 7 patients was chest pain. Four patients had significant ST-segment elevation, and the remaining 4 had T-wave inversions on their admission electrocardiograms. Mean peak troponin I was moderately elevated (3.7 +/- 4.5 ng/dl). The mean echocardiographic left ventricular ejection fraction was 40 +/- 10% on admission and increased significantly to 63 +/- 4% at 1-month follow-up (p <0.0001). All patients but 1 had abnormal corrected Thrombolysis In Myocardial Infarction frame counts (>27 frames) in >or=1 major epicardial coronary artery. All patients were alive and without major adverse cardiac events at 6-month follow-up. In conclusion, transient left ventricular apical ballooning should be considered in the differential diagnosis of patients presenting with suspected acute coronary syndromes, because it may account for approximately 2% of hospital admissions.     

Left ventricular free wall rupture in transient left ventricular apical ballooning.

A 79-year-old woman presented with chest pain. Her symptoms, combined with the results of an electrocardiogram, echocardiogram and laboratory investigations were compatible with an extensive acute anterior myocardial infarction. However, emergency coronary angiography showed no stenotic lesion in any coronary artery, but left ventriculography revealed apical ballooning akinesis and basal hyperkinesis and she was diagnosed as having transient left ventricular apical ballooning. After 7 days, she suddenly went into cardiopulmonary arrest because of cardiac tamponade. The autopsy revealed a free wall rupture. Generally, the prognosis in transient left ventricular apical ballooning is good; left ventricular free wall rupture is very rare.     

Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome

Takotsubo is a reversible cardiomyopathy, often triggered by a stressful event. It combines clinical features mimicking a myocardial infarction, transient apical ballooning of the left ventricle, normal coronary arteries and a small rise in troponin level. There is a striking female predominance with mean age ranging from 65 to 76 years among series. Preceding stressful event is documented in 50 to 100% of patients. The most common clinical presentation is an angor-like chest pain with ST-segment elevation on the electrocardiogram (70%). The prognosis is excellent even if serious complications may occur: pulmonary oedema, cardiogenic shock, transient dynamic intraventricular gradient, life-threatening arrhythmias. In-hospital mortality is in the range of 0 to 10%. The recurrence rate is low. The precise physiopathology of the syndrome remains unknown but catecholamine mediated myocardial stunning is the most favored explanation.     

Transient left ventricular apical ballooning.

We describe the case of an elderly woman patient referred for primary angioplasty for acute anterior myocardial infarction, which developed after intense emotional stress. The coronary angiogram was surprisingly normal, but left ventriculography showed severe apical dilatation and dyskinesia, confirmed by echocardiography. By this time we suspected a syndrome of transient apical ballooning without coronary stenosis, which mimics acute myocardial infarction. She underwent medical therapy and subsequent clinical evolution was favorable, with complete recovery of left ventricular systolic function. We discuss the clinical setting and the pathophysiologic mechanisms of this syndrome.     

Assessment of clinical features in transient left ventricular apical ballooning

OBJECTIVES: We sought to assess the clinical features of transient left ventricular (LV) apical ballooning. BACKGROUND: Although several cases regarding transient LV apical ballooning have been reported, the etiology remains unknown. METHODS: We investigated 17 patients (14 women, median age 74 years old with a range of 54 to 91 years old) who fulfilled the following criteria: 1) transient LV apical ballooning; 2) ST-T segment change in several leads in electrocardiogram; and 3) no history of old myocardial infarction, valvular heart disease, subarachnoid hemorrhage, or pheochromocytoma. RESULTS: Emotional and physical stress were observed in 16 patients (94%). Technetium-99m tetrofosmin tomographic imaging revealed decreased uptake at the apex of the left ventricle in 11 patients (85%) that later returned to uniform. No significant stenosis or angiographical slow flow in epicardial coronary arteries was observed (n = 9). Provocative focal vasospasm was induced in only one patient (14%) (n = 7). Moreover, no significant abnormality in the coronary microcirculation was detected by Doppler guidewire (n = 3) or contrast echocardiography (n = 1). No patients showed a rise in viral antibody titers. Biopsy specimens revealed interstitial fibrosis in six patients (100%) and slight cell infiltration in three others (50%) (n = 6). CONCLUSIONS: These findings suggested that neither abnormalities in the coronary circulation nor acute myocarditis was related to the etiology. Although neurogenic stunned myocardium induced by emotional or physical stress was suggested as the etiology, further investigations are necessary.     

Transient cerebral ischemic attack induced by transient left ventricular apical ballooning

A 57-year-old woman had transient right hemiplegia 2 days after physical stress. An electrocardiogram exhibited T-wave inversion with QT prolongation. An echocardiogram revealed akinesia of the entire left ventricle except for the basal region. Cranial computed tomography and transthoracic echocardiography revealed an apical thrombus that disappeared 1 month later. Coronary angiography was normal. After 3 months, left ventricular wall motion had completely normalized.     

Out-of-hospital cardiac arrest caused by transient left ventricular apical ballooning syndrome

We describe a case of out-of-hospital cardiac arrest due to ventricular fibrillation in a patient with transient left ventricular apical ballooning syndrome. Our report confirms that left ventricular apical ballooning may have the same complications of myocardial infarction, adding the early ventricular fibrillation to the previous findings of left ventricular wall rupture, ventricular arrhythmias during hospitalization and complete atrio-ventricular block. Moreover, left ventricular apical ballooning may have different and unusual clinical onsets, including sudden cardiac death due to ventricular tachyarrhythmias in the absence of associated symptoms. Therefore, in our opinion left ventricular apical ballooning may be considered as a possible cause of sudden death in otherwise healthy women.     

A case of transient left ventricular apical ballooning with an unusual complication

A retrospective study of patients with acute myocardial ischemia syndrome, mainly middle-aged and elderly women, was published in july 2001. The main features of acute myocardial ischemia were typical triggering circumstances, initial ECG mimicking acute myocardial infarction (AMI with transient appearance of Q waves and large negative T waves), mild or no enzymatic changes, and a combination of a normal coronary angiogram and transient left ventricular apical dyskinesia that normalized within days. The clinical course and prognosis were completely different from those of conventional AMI, with an increased number of acute-phase complications such as acute pulmonary edema, cardiogenic shock, and ventricular tachycardia. Despite this, the long-term outcome was better than that of AMI. We report a typical case diagnosed in a Spanish woman who developed embolic stroke, a complication not previously described, most likely related with her apical dyskinesia.     

Modulation of ventricular repolarization in patients with transient left ventricular apical ballooning: a case control study

Objective: Even though diffuse T wave inversion and prolongation of the QT interval in the surface electrocardiogram (ECG) have been consistently reported in patients with transient stress‐induced left ventricular apical ballooning (AB), ventricular repolarization has not yet been systematically investigated in this clinical entity. Background: AB, an emerging syndrome that mimics acute ST‐segment elevation myocardial infarction (MI), is characterized by reversible left ventricular wall motion abnormalities in the absence of obstructive coronary heart disease and significant QT interval prolongation. Methods: We prospectively enrolled 22 consecutive patients (21 women, median age 65 years) with transient left ventricular AB. A total of 22 age‐, gender‐, body‐mass‐index‐, and left‐ventricular‐function‐matched patients with acute anterior ST‐segment elevation MI undergoing successful direct percutaneous coronary intervention for a proximal occlusion of the LAD, as well as 22 healthy volunteers served as control groups. Beat‐to‐beat QT interval and QT interval dynamicity were determined from 24‐hour Holter ECGs, recorded on the third day after hospital admission. Results: There were no significant differences in baseline clinical characteristics, except higher peak enzyme release in MI patients. Compared with MI patients, AB patients exhibited significantly prolonged mean QT intervals and rate‐corrected QT intervals (QT: 418 ± 37 vs 384 ± 33 msec, P < 0.01; QTc_Bazett: 446 ± 40 vs 424 ± 35 msec, P < 0.05; QTc_Fridericia: 437 ± 35 vs 412 ± 31 msec, P < 0.05). Mean RR intervals tended to be higher in AB patients, without reaching statistical significance (877 ± 96 vs 831 ± 102 msec, P = NS). The linear regression slope of QT intervals plotted against RR intervals was significantly flatter in AB patients at both day‐ and nighttime (QT/RR slope_day: 0.18 ± 0.04 vs 0.22 ± 0.06, P < 0.01; QT/RR slope_night: 0.12 ± 0.03 vs 0.17 ± 0.05, P < 0.01). Conclusion: The present study is the first to demonstrate significant differences of QT interval modulation in patients with transient left ventricular AB and acute ST‐segment elevation MI. Even though transient AB is associated with a significant QT interval prolongation, rate adaptation of ventricular repolarization (i.e., QT dynamicity) is not significantly altered, suggesting a differential effect of autonomic nervous activity on the ventricular myocardium in transient AB and in acute MI.     

Multiple episodes of a transient global left ventricular dysfunction reminiscent to apical ballooning

A new cardiac syndrome with transient left ventricular dysfunction has been recently reported and is referred to as Tako-Tsubo cardiomyopathy, which is characterized by a transient akinesia of the apex and compensatory basal hyperkinesis. Today, the etiology remains unknown. We report for the first time of a patient with multiple episodes of a transient global left ventricular dysfunction which is reminiscent to apical ballooning. These episodes were always preceded by severe emotional stress proposing a potential common pathomechanism.