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.     

Shoshin beriberi with vasospastic angina pectoris possible mechanism of mid-ventricular obstruction: possible mechanism of mid-ventricular obstruction.

A 73-year-old heavy drinker was admitted to hospital in a state of shock. He had been suffering from frequent angina at rest, causing him to drink more heavily in an effort to overcome his anginal chest pain. He had been drinking hard each day and had not eaten for 4 weeks. His hemodynamic state on admission showed high-output heart failure. Echocardiography revealed hyperkinesis of the left ventricle and mid-ventricular obstruction with peak intraventricular gradients of 30 mmHg. Although no improvement was seen despite administering the maximal dose in catecholamine therapy, his condition improved rapidly after vitamin B(1) was administered. Cardiac catheterization revealed mid-ventricular obstruction with an apical aneurysm. Coronary artery spasm was induced by injecting acetylcholine in the distal site of the left anterior descending artery, which perfused the area of the apical aneurysm. In the present case, both left ventricular hyperkinesis caused by shoshin beriberi and apical myocardial infarction caused by frequent coronary spasms produced mid-ventricular obstruction with an apical aneurysm.     

Acute myocardial infarction

Transient left ventricular apical ballooning or Takotsubo syndrome (TS) is characterized by transient left ventricular dysfunction, electrocardiographic changes that mimic acute myocardial infarction (AMI), and minimal release of myocardial enzymes, with no evidence of obstructive coronary artery disease. Although prognosis and outcome are relatively good, reported complications include intraventricular thrombi and embolic events. We report an extremely rare case of AMI complicating the early in‐hospital course of a patient with TS. © 2013 Wiley Periodicals, Inc.     

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 left ventricular apical ballooning in a patient with bicuspid aortic valve created a left ventricular thrombus leading to acute renal infarction.

A 44-year-old woman had tako-tsubo-like ventricular dysfunction with chest pain and ST segment elevation on the ECG. Echocardiography revealed a bicuspid aortic valve with moderate to severe aortic regurgitation. She developed mild heart failure during the clinical course, but the medication (furosemide, enalapril, and asprin) had to be stopped because of skin eruptions. Four weeks after ceasing the antiplatelet agent, she was re-admitted with acute renal infarction. Enhanced chest computed tomography revealed a filling defect in the left ventricle and echocardiography showed a high echogenic mass in the left ventricular apical wall. These findings strongly suggested that the renal infarction was caused by an embolism derived from a left ventricular thrombus that formed during the clinical course of the transient left ventricular apical ballooning. Anticoagulation therapy with urokinase and warfarin successfully lysed the thrombus. Left ventricular thrombus should be considered a complication of transient left ventricular apical ballooning, especially in patients with organic heart disease.     

Acute cardiac sympathetic disruption and left ventricular wall motion abnormality in takotsubo syndrome

Abstract

Takotsubo syndrome (TS) is characterized by a unique pattern of transient circumferential left ventricular wall motion abnormality (LVWMA). The LVWMA in TS may be localized to the apical, mid-apical, mid-ventricular, mid-basal or basal regions of the left ventricle. Focal and generialized (global) LVWMA have also been reported. In the acute phase of TS, the hyperkinetic valve-like motion of the basal segments and/or the hyperkinetic slingshot-like motion of the apical segments combined with the firm stunned a-, hypokinetic segments result in a conspicuous left ventricular ballooning during systole. The LVWMA in TS follows most probably the local cardiac sympathetic nerve distribution and caused by local cardiac sympathetic disruption and noradrenaline spillover.     

Thrombo‐embolic complications in takotsubo syndrome: Review and demonstration of an illustrative case

Thrombo‐embolism is one of the serious complications of takotsubo syndrome (TS) in addition to heart failure, pulmonary edema, cardiogenic shock, cardiac arrest, life‐threatening arrhythmias, left ventricular outlet tract obstruction, mitral regurgitation, cardiac rupture, and death. The most common cardio‐embolic events in TS are cerebral, renal, and peripheral embolism. Approximately, one‐third of patients with left ventricular thrombus (LVT) in TS develop embolic complications. Cardio‐embolism in TS may occur with or without the presence of detectable LVT. In the present report, the thrombo‐embolic complications in TS with the emphasis on the association of TS to both acute coronary syndrome (ACS) including coronary embolism and ischemic stroke including cerebral embolism are reviewed. This serious complication is elucidated by demonstration of the case of a 67‐year‐woman with mid‐apical TS complicated by LVT, left anterior descending artery (LAD) and left middle cerebral artery (segment M2) thrombo‐embolic occlusions. The cerebral artery thrombotic occlusion was treated successfully with endovascular thrombectomy with complete resolution of the neurological deficits. There was spontaneous recanalization of the apical LAD occlusion verified by cardiac computed tomography angiography.     

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.     

Tako-Tsubo-Kardiomyopathie: Differentialdiagnose des akuten Koronarsyndroms

We report on a 71-year-old female, who was admitted to the emergency department because of acute chest pain. Due to similar symptoms the previous day an acute coronary syndrome had been ruled out non-invasively by ECG and laboratory tests. Acute physical or emotional stressful events were negated by the patient. The ECG showed newly diagnosed inverted T waves in the precordial leads. The lab showed a minimal release of myocardial enzymes and proteins. Echocardiographically apical hypokinesia was observed. Coronary angiography revealed no significant occlusion and showed left ventricular apical ballooning. Due to the symptoms resembling acute myocardial infarction, the absence of obstructive coronary disease and the typical left ventricular apical ballooning we assume that the patient had Tako-Tsubo cardiomyopathy.     

Right ventricular infarction with tricuspid insufficiency and chronic right heart failure.

A patient with chronic right heart failure and probable tricuspid insufficiency associated with an inferior myocardial infartion is described. Angiograms demonstrated total occlusion of the right coronary artery at its origin, a patent venous bypass graft to the mid-right coronary artery and hypokinesia of the inferior wall of both the right and left vebtricles. Clinical data indicated a greater impairment of right than of left ventricular function. It is proposed that infarction of the right ventricle resulted in chronic right heart failure and tricuspid insufficiency.     

Transient impairment of myocardial perfusion in a patient with apical ballooning syndrome

We describe a case of a 76-year-old woman who presented with chest pain after a violent argument. On admission the electrocardiogram showed 1-mm ST segment elevation in II, III, aVF, V3-V6 leads; the subsequent electrocardiogram showed T-wave inversion in the same leads. Peak troponin I level was 7.3 ng/dl (normal <0.4 ng/dl). Emergency angiography demonstrated the so-called "apical ballooning", in the absence of any obstructive coronary artery disease. A myocardial contrast echocardiogram performed 5 days later showed a large perfusion defect in the akinetic apical region of the left ventricle; at 1-month follow-up myocardial perfusion and left ventricular wall motion became completely normal. In patients with apical ballooning syndrome a catecholamine-mediated endothelial injury might be responsible of a microvascular coronary dysfunction which causes myocardial ischemia and subsequent myocardial stunning.     

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.     

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.     

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.     

Transient left ventricular apical ballooning syndrome--a case report

We present a case of a 78-year-old female who was admitted to the hospital due to clinical and electrographic features of ST-elevation acute myocardial infarction. Coronary angiography revealed normal coronary arteries and severe left ventricular contractility abnormalities, detected initially by echocardiography, which resolved within 20 days from hospital admission. Because of these findings and typical echocardiographic picture, a transient left ventricular apical ballooning syndrome (the tako-tsubo syndrome) was diagnosed.     

Clinical Characteristics,Demographics and Prognosis of Transient Left Ventricular Apical Ballooning Syndrome

Background: Transient left ventricular apical ballooning syndrome also called Tako-Tsubo cardiomyopathy is defined as a syndrome consisting of stress induced apical ballooning of the left ventricle and normal coronary arteries. The majority of the published reports are case reports or case series with a small number of patients. The goal of this study was to perform statistical analysis of reported cases and case series in the literature in order to study demographic, clinical characteristics and prognosis of this syndrome. Method: A PubMed search of the terms transient left ventricular apical ballooning, Tako-Tsubo, takotsubo, and apical cardiomyopathy was conducted for this study. All reports that contained information about individual patients were included in the statistical analysis. Results: The majority of the patients were women (93.5%). Asians were the largest group (57.2%) followed by Caucasians (40%). The presentations mimics an acute myocardial infarction. The most frequent presenting symptom was chest pain (65.9%) followed by dyspnea (16.2%). ST elevation was the most common ECG abnormality (87.5%). Contrary to most reports, this is not a benign disease with complications occurring in 18.9% and death in 3.2%. The most common complication was shock followed by left ventricular thrombus formation and congestive heart failure. Conclusion: Apical ballooning syndrome occurs most commonly in women and is associated with high complication rate. There are significant differences in presenting symptoms between race and gender which warrant further investigation.     

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.     

Biventricular involvement in transient apical ballooning syndrome

Transient apical ballooning syndrome (Takotsubo cardiomyopathy) is an acute cardiac syndrome mimicking ST-elevation myocardial infarction. It is characterized by ventricular wall motion abnormalities confined to the apical regions of the left ventricle. Here we describe an 80-year old woman presenting with acute shortness of breath. Echocardiography demonstrated left and right ventricular apical akinesia and basal hyperkinesia. Cardiac catheterisation disclosed minimal atherosclerotic changes of the coronary arteries. Both symptoms and echocardiographic findings resolved completely within one week.     

Five cases of transient left ventricular apical ballooning--the experience of a Portuguese center.

Transient left ventricular apical dyskinesia (apical ballooning syndrome, ABS) is characterized by transient alterations in regional wall motion, involving the mid and apical segments of the left ventricle, as well as electrocardiographic alterations, mimicking ST-elevation acute myocardial infarction, in the absence of obstructive disease of the epicardial coronary arteries. In this article, we present a series of five cases of ABS and a theoretical review of the syndrome.     

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.