Takotsubo cardiomyopathy, or broken-heart syndrome

Takotsubo cardiomyopathy mimics acute coronary syndrome and is accompanied by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis. In Japanese, "takotsubo" means "fishing pot for trapping octopus," and the left ventricle of a patient diagnosed with this condition resembles that shape. Takotsubo cardiomyopathy, which is transient and typically precipitated by acute emotional stress, is also known as "stress cardiomyopathy" or "broken-heart syndrome."Herein, we describe the clinical angiographic characteristics of 4 patients who exhibited this syndrome, and we review the existing literature and propose reasons to conduct prospective studies.     

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.     

Atypical Transient Stress-Induced Cardiomyopathies with an Inverted Takotsubo Pattern in Sepsis and in the Postpartal State

Several cases of inverted Takotsubo cardiomyopathy—a variant form with hyperdynamic left ventricular apex and akinesia of the left ventricular base and mid-portion—have been reported recently, especially in association with cerebrovascular accidents and catecholamine cardiomyopathies. Herein, we describe 2 cases of inverted Takotsubo cardiomyopathy: one that occurred in a middle-aged woman who had a septic condition, and another in a young woman who was in the postpartal state. Such cases have not been reported previously.Key words: Cardiomyopathies/physiopathology/therapy/ultrasonography, coronary angiography, echocardiography, heart ventricles/physiopathology/radiography, postpartum period, sepsis, ventricular dysfunction/diagnosis/physiopathology, ventricular dysfunction, leftStress-induced cardiomyopathy is characterized by a transient abnormality of left ventricular (LV) apical wall motion, electrocardiographic changes, and minimal cardiac enzyme release. The condition mimics acute coronary syndrome in patients who have no angiographic stenosis upon coronary angiography. Recently, atypical stress-induced cardiomyopathies without involvement of the LV apex have been reported.¹ Most of the cases were transient midventricular ballooning syndrome with midventricular akinesia and normal wall motion of the LV base and apex,^1–3 and some were the “inverted Takotsubo pattern” cardiomyopathy that is characterized by a hyperdynamic LV apex and akinesia of the LV base and mid-portion.^4–6 Here, we describe 2 cases of inverted Takotsubo cardiomyopathy, one of which occurred in a middle-aged woman with a septic condition and one in a young woman who was in the postpartal state.     

Takotsubo cardiomyopathy as a potential cause of long QT syndrome and torsades de pointes

Takotsubo cardiomyopathy is an increasingly reported syndrome characterized by transient apical left ventricular dysfunction in absence of flow limiting coronary artery disease. Prolongation of QT interval associated with Takotsubo cardiomyopathy has been previously reported in published case series but none of these series reported occurrence of torsades de pointes. Reported here is a case of Takotsubo cardiomyopathy resulting in QT prolongation and torsades de pointes in an emotionally distressed woman. The patient had a complete recovery of cardiac function in a week. Takotsubo cardiomyopathy should be considered among the causes of long QT syndrome and torsades de pointes.     

Apical ballooning syndrome in first degree relatives

Apical ballooning syndrome (Takotsubo cardiomyopathy) is an unusual stress-related reversible cardiomyopathy occurring commonly in postmenopausal females. Genetic etiology of this condition is uncertain. A 68-year-old female and her daughter aged 43 got admitted to our institute simultaneously with acute chest pain following demise of one of their close relative. Both had features typical of Takotsubo cardiomyopathy and recovered completely. This reports point to the possible genetic predisposition to this abnormality.     

Reverse or inverted apical ballooning in a case of refeeding syndrome

Takotsubo cardiomyopathy is characterized by the development of transient left ventricular regional wall motion abnormalities, in the absence of significant coronary artery obstruction. This syndrome usually occurs in women and is frequently associated with an intense emotional or physical stress. It usually involves apical segments, but in the recent years atypical forms have been described. Inverted or reverse Takotsubo is a variant in which the basal and midventricular segments are hypokinetic, sparing contractile function of the apex. In this report we describe the case of a 54-year-old woman, with chronic malnutrition, initially admitted because of hypoglycemia and severe electrolyte disturbance due to a refeeding syndrome. Within the next hours she experienced acute cardiac symptoms and developed heart failure with low cardiac output. Electrocardiogram (ECG), elevation of troponin and echocardiographic findings were consistent with inverted Takotsubo cardiomyopathy. To the best of our knowledge, this is the first incidence reported of inverted Takotsubo triggered by refeeding syndrome.     

Cardiac implantable devices and Takotsubo syndrome. A rare but potential eventuality

Takotsubo cardiomyopathy is a syndrome which mimics acute myocardial infarction (AMI) occurring often after an emotional or physical stress. We report the case of a female patient who suffered from Takotsubo cardiomyopathy associated to a coronary fistula after pacemaker implantation. Its occurrence should be always remembered by the implanters, avoiding it by an appropriate psychological screening and use of conscious sedation.     

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.     

Takotsubo cardiomyopathy in a patient with severe hyponatremia associated with syndrome of inappropriate antidiuretic hormone

Although the etiology of Takotsubo cardiomyopathy (stress-induced cardiomyopathy) is unknown, there is a wide variability in the psychological and physical triggers for Takotsubo cardiomyopathy. We report here a case of Takotsubo cardiomyopathy associated with severe hyponatremia.     

Takotsubo syndrome: a predominantly female CV disorder,from the perspective of primary care

We describe two cases of Takotsubo syndrome and discuss the issues relating to diagnosis and patient communication that they raise.Key words: cardiomyopathy, female, myocardial dysfunction, stress, Takotsubo     

Delayed Kounis syndrome and acute renal failure after wasp sting

A fifty-seven year old gentleman developed hemolysis induced oliguric acute renal failure following multiple wasp stings. Patient was hemodynamically stable on dialytic support. Twelve days later, although the patient was recovering from renal failure, he developed sudden onset of tachyarrythmias and echocardiography demonstrated a Takotsubo type of cardiomyopathy. He was managed with amiodarone and hemodialysis. After two more episodes of deterioration, the patient made full recovery from both the renal and cardiac toxicity. A case of delayed Kounis syndrome associated with Takotsubo cardiomyopathy in the setting of acute renal failure is described. The possible mechanism of such a presentation is discussed.     

Takotsubo cardiomyopathy: An under-recognized myocardial syndrome

Takotsubo cardiomyopathy is characterized by reversible left ventricular dysfunction with apical ballooning and is triggered by marked psychological or physiological stress in the absence of significant epicardial coronary artery disease. Clinically, this unique myocardial syndrome mimics acute myocardial infarction, and it has been considered to be a rare entity with a good prognosis. The literature on takotsubo cardiomyopathy is limited by selection bias and patient heterogeneity, but recent data suggest the syndrome is more prevalent, e.g., in critically ill, non-cardiac patients. Prompt diagnosis and aggressive therapy are essential for a rapid recovery. Clinicians should increase their awareness of this syndrome and more research should be carried out on the epidemiology, pathophysiology, and treatment of takotsubo cardiomyopathy.     

Reversible electrocardiogram changes and cardiomyopathy secondary to baclofen withdrawal syndrome

Baclofen withdrawal syndrome is a rare and potentially life-threatening condition manifesting with autonomic dysreflexia, high fevers, spasticity, seizures, and multiorgan failure. Reversible cardiomyopathy due to this condition is extremely rare. A high level of suspicion is needed to recognize this condition and start an early intervention to improve patient outcome. Electrocardiographic ST-segment elevation in lead aVR was previously described in association with left main, left anterior descending, and triple-vessel coronary artery disease as well as Takotsubo cardiomyopathy. In this article we present a rare case of reversible cardiomyopathy due to baclofen withdrawal syndrome associated with diffuse ST-segment depressions and ST-segment elevation in lead aVR.     

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, left ventricular apical ballooning syndrome, and broken heart syndrome, is a clinical entity first described in the early 1990s in Japan and now receiving increased attention in the United States. The clinical features include an onset of chest pain mimicking that of an acute myocardial infarction, electrocardiogram changes similar to those of an acute myocardial infarction, normal coronary arteries on cardiac catheterization, and a signature appearance on echocardiogram. Takotsubo cardiomyopathy results in a significantly decreased ejection fraction that, as long as the patient receives appropriate hemodynamic support, typically undergoes spontaneous reversal. This article describes the history, clinical presentation, and management strategies for Takotsubo cardiomyopathy and provides a case study.     

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.     

Catecholaminergic polymorphic ventricular tachycardia and midventricular Takotsubo cardiomyopathy: a novel association?

Takotsubo cardiomyopathy (TTC) is a recently recognized clinical syndrome characterized by transient ventricular dysfunction in the absence of obstructive coronary artery disease. TTC primarily affects postmenopausal women; TTC in children and adolescents is only rarely reported. Furthermore, simultaneous occurrence of Takotsubo cardiomyopathy and primary electrical diseases has been previously reported in only four recent cases of female patients with congenital long QT syndrome. Here, we report the novel association of catecholaminergic polymorphic ventricular tachycardias and a midventricular type of TTC observed in a young female patient.     

Atypical takotsubo cardiomyopathy: dobutamine-precipitated apical ballooning with left ventricular outflow tract obstruction

Takotsubo cardiomyopathy, or transient apical ballooning syndrome, is a recently recognized form of transient left ventricular dysfunction that is presumably caused by stress. Takotsubo cardiomyopathy can clinically resemble an acute coronary syndrome. Reported cases have been preceded by emotional stress or medical illness. Herein, we report a fatal case of takotsubo cardiomyopathy that followed a dobutamine stress test. We believe that the dobutamine infusion led to stress-induced cardiomyopathy with a dynamic left ventricular outflow tract obstruction. To our knowledge, there is only 1 other report of an association between dobutamine infusion and the development of takotsubo cardiomyopathy.     

"Broken heart syndrome": catecholamine surge or aborted myocardial infarction?

Takotsubo cardiomyopathy, also called transient left ventricular apical ballooning or "broken heart syndrome", is a cardiac condition that mimics the clinical presentation of acute coronary syndrome but without any evidence of obstructive atherosclerotic coronary artery disease. An episode of intense emotional or physiologic stress, serving as the nidus for a catecholamine surge, has been reported prior to presentation and is presumed to be the triggering factor playing the pathogenic role. We report a unique case of Takotsubo cardiomyopathy without any known precipitating factors. After reviewing multiple case reports and review articles, the evidence supporting a "catecholamine surge" is empirically plausible; however, our case calls this theory into question. The "aborted MI" hypothesis is more convincing as an all-inclusive nidus for the pathogenesis and clinical presentation described in Takotsubo syndrome. More detailed studies and research are needed to ascertain the pathogenesis and optimal management of this syndrome.     

Biventricular Takotsubo syndrome in a patient with coronary abnormality and end-stage renal disease

The Takotsubo syndrome is a clinical entity consisting of transient, regional left ventricular (LV) contraction abnormalities in the absence of significant epicardial coronary artery disease. Patients usually present with acute hemodynamic deterioration following an emotional or physical stress. The Takotsubo syndrome is uncommon among patients with end-stage renal disease (ESRD) and patients with congenital coronary abnormalities, such as right coronary artery (RCA) originating from left sinus of Valsalva. Here we describe a patient presenting with acute respiratory distress and anterolateral ST-T segment changes, with negative troponin-I and elevated levels of brain natriuretic peptide. Coronary angiography showed a right coronary artery arising from the left sinus of Valsalva without obstructive coronary artery disease, while ventriculography and echocardiogram showed findings compatible with apical ballooning. Magnetic resonance imaging confirmed the diagnosis of a biventricular Takotsubo cardiomyopathy.     

Inverted‐Takotsubo Pattern Cardiomyopathy Secondary to Pheochromocytoma: A Clinical Case and Literature Review

Takotsubo cardiomyopathy is an increasingly recognized clinical syndrome of transient left ventricular dysfunction, commonly with apical ballooning, in the context of physical or emotional stress. Recently, an inverted‐Takotsubo contractile pattern has been described with hypokinesis of the basal and mid‐ventricular segments and sparing of the apex. We report a case of a 30‐year‐old man presenting with transient left ventricular dysfunction in an inverted‐Takotsubo contractile pattern, associated with a newly discovered pheochromocytoma, and present a literature review of the inverted‐Takotsubo contractile pattern cardiomyopathy. Copyright © 2010 Wiley Periodicals, Inc.