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.     

心尖球形综合征一例

1病例资料患者男性,62岁,因活动性胸闷、气促伴双下肢水肿1周于2010年4月26日入院。入院前一周因受凉后出现活动性胸闷、气促、双下肢水肿,伴咳嗽、咳少量白痰,夜间不能平卧。4月19日曾至外院就诊查心电图：窦速,左室肥厚,     

Long QT syndrome and torsade de pointes in transient left ventricular apical ballooning syndrome

A recently reported cardiac syndrome of reversible left ventricular apical ballooning, also called Takotsubo cardiomyopathy or ampulla cardiomyopathy, clinically resembles acute myocardial infarction and presents with chest pain, anterior electrocardiographic changes and minimal elevation of cardiac enzymes in absence of myocardial ischemia or injury. Left ventricular function recovers completely in days to weeks. This syndrome is likely a non-ischemic, metabolic-dependent syndrome caused by stress-induced activation of the cardiac adrenoceptors, and results in markedly abnormal ventricular repolarization. Reported here is a case of left ventricular apical ballooning syndrome with QT interval prolongation in a young man who developed torsade de pointes and experienced aborted sudden cardiac death. Patient had a complete recovery of cardiac function and normalization of QT interval in a few days. The syndrome of transient left ventricular apical ballooning could be considered among the causes of long QT syndrome and torsade de pointes.     

Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction

Objective

The presentation and electrocardiographic (ECG) characteristics of transient left ventricular apical ballooning syndrome (TLVABS) can be similar to that of anterior ST-segment elevation myocardial infarction (STEMI). We tested the hypothesis that the ECG on presentation could reliably differentiate these syndromes.

Subjects and Methods

Between January 1, 2002 and July 31, 2004, we identified 18 consecutive patients with TLVABS who were matched with 36 subjects presenting with acute anterior STEMI due to atherothrombotic left anterior descending coronary artery occlusion.

Results

All patients with TLVABS were women (mean age, 72.0 ± 13.1 years). The heart rate, PR interval, QRS duration, and corrected QT interval were similar between groups. Distribution of ST elevation was similar, but patients with anterior STEMI exhibited greater ST elevation. Regressive partitioning analysis indicated that the combination of ST elevation in lead V₂ of less than 1.75 mm and ST-segment elevation in lead V₃ of less than 2.5 mm was a suggestive predictor of TLVABS (sensitivity, 67%; specificity, 94%). Conditional logistic regression indicated that the formula: (3 × ST-elevation lead V₂) + (ST-elevation V₃) + (2 × ST-elevation V₅) allowed possible discrimination between TLVABS and anterior STEMI with an optimal cutoff level of less than 11.5 mm for TLVABS (sensitivity, 94%; specificity, 72%). Patients with TLVABS were less likely to have concurrent ST-segment depression (6% vs 44%; P = .003).

Conclusions

Women presenting with TLVABS have similar ECG findings to patients with anterior infarct but with less-prominent ST-segment elevation in the anterior precordial ECG leads. These ECG findings are relatively subtle and do not have sufficient predictive value to allow reliable emergency differentiation of these syndromes.     

心尖球形综合征和ST段抬高型心肌梗死QT离散度分析

心尖球形综合征(TLVABS)由于临床表现、心电图显示与早期ST段抬高型心肌梗死(STEMI)非常相似,但其预后相差甚远。QT离散度(QTd)为同步记录12导联心电图中测量的最大QT间期(QTmax)与最小QT间期(QTmin)之差,是一个比较好的参数用来评价心脏复极的同步性和自主功能[1]。随着心脏复极不同步性的增加,会增加心室恶     

Transient left ventricular apical ballooning following a prolonged ablation

The authors report a case of transient left ventricular apical ballooning after a prolonged electrophysiology procedure. Interventional electrophysiologists should be aware of this syndrome as a potential complication.     

Assessment of coronary flow reserve by transthoracic Doppler echocardiography in left apical ballooning syndrome

We present the time course of transthoracic coronary flow reservein the left anterior descending artery in a patient who suffereda transient left apical ballooning syndrome.     

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.     

Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review.

AIMS: To clarify the major features of the apical ballooning syndrome, we performed a systematic review of the existing literature. METHODS AND RESULTS: Review of all relevant case series using the MEDLINE and EMBASE databases resulted in the identification of 14 studies. These studies suggest that the apical ballooning syndrome accounts for approximately 2.0% of ST-segment elevation infarcts, with most cases described in post-menopausal women. The most common clinical presentations are chest pain and dyspnoea, reported in 67.8 and 17.8% of the patients, respectively. Cardiogenic shock (4.2% of the patients) and ventricular fibrillation (1.5%) were not infrequent. ST-segment elevation was reported in 81.6% of the patients, T wave abnormalities in 64.3%, and Q waves in 31.8%. Cardiac biomarkers were usually mildly elevated, as reported in 86.2% of the patients. Typically, patients had left ventricular (LV) dysfunction on admission, with mean ejection fraction ranging from 20 to 49%. However, over a period of days to weeks, all patients experienced dramatic improvement in LV function. The onset of symptoms was often preceded by emotional (26.8%) or physical stress (37.8%). Norepinephrine concentration was elevated in 74.3% of the patients. Prognosis was generally excellent, with full recovery in most patients. In-hospital mortality was 1.1%. Only 3.5% of the patients experienced a recurrence. CONCLUSION: Clinicians should consider this syndrome in the differential diagnosis of patients presenting with chest pain, especially in post-menopausal women with a recent history of emotional or physical stress.     

Survival in patients found to have ventricular fibrillation after cardiac arrest witnessed outside hospital

Since 1980 an Emergency Medical Service (EMS) system with atwo-tier ambulance service has been operating in Göteborg.During this 12-year period, all cardiac arrests outside hospitalhave been monitored. Cardiopulmonary resuscitation (CPR) trainingfor the general public began in 1985 and, by the end of 1992,125 000 persons had been trained. The aim of this study was to define the factors associated withan increased chance of survival after cardiac arrest witnessedout-of-hospital and secondary to ventricular fibrillation. The study group comprises all patients with cardiac arrest witnessedoutside hospital in Goteborg between 1980 and 1992, in whomCPR was initiated by our EMS and ventricular fibrillation observedat the first ECG recording. In a multivariate analysis of age, sex, time of collapse, intervalbetween collapse and first defibrillation, bystander-initiatedCPR, the following factors were associated with an increasedchance of being discharged from hospital: (1) Short intervalbetween collapse and first defibrillation (P<0.001); (2)Bystander-initiated CPR fP<0.001); and (3) Age (P<0.05). Among patients with an out-of-hospital cardiac arrest who werefound by the EMS personnel to have ventricular fibrillation,the predictors of survival were: interval between collapse anddefibrillation, bystander-initiated CPR and age.     

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.     

Sudden cardiac death: An increasingly recognized presentation of apical ballooning syndrome (Takotsubo cardiomyopathy)

We present an unfortunate case of a previously healthy woman who suffered an out-of-hospital cardiac arrest in the setting of severe emotional distress, likely due to apical ballooning syndrome. This case highlights the fact that although patients with apical ballooning syndrome typically do well following recovery from transient left ventricular dysfunction, they should be monitored closely in the acute setting due to the potential for life-threatening arrhythmias.     

Early left ventricular ejection fraction as a predictor of survival after cardiac arrest

Background: Cardiopulmonary resuscitation and early defibrillation have been shown to improve outcomes of cardiac arrest. The significance of the post-arrest echocardiogram, specifically the left ventricular ejection fraction (LVEF) is unknown. Methods: We performed a retrospective cohort study of patients who suffered from cardiac arrest between 1 January 2009 and 31 December 2013. We included all patients who achieved return of spontaneous circulation (ROSC), and were admitted to the intensive care unit (ICU) or coronary care unit (CCU) of a tertiary care academic center. Patients who underwent echocardiography within 24 h of cardiac arrest were included for analysis. The primary outcome was survival. Results: We identified 151 patients who achieved ROSC of which 97 underwent post-arrest echocardiogram within 24 h. 70.8% were males and the mean age was 67.8 years (SD: 15.9). The mean LVEF at 24 h was 35.7 (SD: 17.8). LVEF > 40% was not a predictor of survival at 30 days or hospital discharge. The only significant predictors on multivariate analyses were age, presence of shockable rhythm and time to ROSC. Conclusion: Although echocardiograms are frequently ordered, LVEF greater than 40% in patients who are resuscitated after a cardiac arrest is not a predictor of survival.     

Reverse or inverted left ventricular apical ballooning syndrome (reverse Takotsubo cardiomyopathy) in a young woman in the setting of amphetamine use

Transient left ventricular apical ballooning syndrome was first described in Japan as "Takotsubo cardiomyopathy." This syndrome has been identified in many other countries. Many variations of this syndrome have been recently described in the literature. One of the rarest is the reverse type of this syndrome, with hyperdynamic apex and complete akinesia of the base (as opposed to the classic apical ballooning). In this article, we report an interesting case of a young woman who presented with this rare type of reverse apical ballooning syndrome occurring after amphetamine use. This report is followed by review of the literature.     

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.     

Time course of electrocardiographic changes in transient left ventricular ballooning syndrome

Background

We sought to describe, for the first time, in detail the time course of electrocardiographic (ECG) changes in transient left ventricular ballooning syndrome (TLVBS) from acute onset until 1 year after presentation.

Methods

The serial ECGs of all patients identified with TLVBS who presented to our cardiology department from August 1998 to August 2012 were analyzed, from admission to 1-year follow-up, with respect to time from onset of symptoms.

Results

In total, 145 TLVBS episodes were identified in 139 patients. In 53% of patients, ST segment elevation was present in the first 3 h after symptom onset, after which there was a steady decline with complete resolution in all patients by 1 month. The presence of T wave inversion (TWI), with or without ST segment depression, was most prevalent between day 1 (60%) and day 30 (71%) from symptom onset, with 17% of patients still exhibiting TWI after 6 to 12 months. At 1 year, approximately 80% of patients had no significant residual ST-T wave changes. In 86% of patients, there was prolongation of the corrected QT (QTc) interval in the acute phase, with normalization of all QTc intervals by day 14.

Conclusions

During the early phase, ECG mimics acute ST elevation myocardial infarction with initial regional ST segment elevation progressing to T wave inversion with or without ST depression. In the majority of patients, significant QTc interval prolongation occurs in the early phase, normalizing by day 14.