Two Cases of Reversible Left Ventricular Hypertrophy during Recovery from Takotsubo Cardiomyopathy

We report 2 cases of reversible ventricular hypertrophy in patients with takotsubo cardiomyopathy (stress‐induced cardiomyopathy) during recovery of cardiac function. The first case involved a 72‐year‐old woman who presented with cerebral infarction. On admission, an elevated troponin I and decreased apical wall motion were observed with normal myocardial perfusion imaging. The second case involved a 79‐year‐old woman who presented with angina, anxiety resulting from emotional stress, slightly decreased apical wall motion, and normal epicardial arteries. In both cases, apical hypertrophy of the left ventricle was observed at approximately 3 weeks after onset, when the wall motion had improved. The ventricular wall gradually became thinner over time. To our knowledge, this is the first report of reversible ventricular hypertrophy in patients with takotsubo cardiomyopathy. We hypothesize the hypertrophic signaling in the myocardium was stimulated by catecholamines, which are the suggested etiology of takotsubo cardiomyopathy, and the hypertrophied myocardium gradually returned to normal as the syndrome receded.     

Takotsubo Cardiomyopathy as a Sequela of Elective Direct-Current Cardioversion for Atrial Fibrillation

In takotsubo cardiomyopathy, the clinical appearance is that of an acute myocardial infarction in the absence of obstructive coronary artery disease, with apical ballooning of the left ventricle. The condition is usually precipitated by a stressful physical or psychological experience. The mechanism is unknown but is thought to be related to catecholamine excess. We present the case of a 67-year-old woman who experienced cardiogenic shock caused by takotsubo cardiomyopathy, immediately after undergoing elective direct-current cardio-version for atrial fibrillation. After a course complicated by left ventricular failure, cardiogenic shock, and ventricular tachycardia, she made a complete clinical and echocardiographic recovery. In addition to this case, we discuss the possible direct effect of cardioversion in takotsubo cardiomyopathy.     

Two Cases of Apical Ballooning Syndrome Masking Apical Hypertrophic Cardiomyopathy

Apical akinesis and dilation in the absence of obstructive coronary artery disease is a typical feature of stress-induced (takotsubo) cardiomyopathy, whereas apical hypertrophy is seen in apical-variant hypertrophic cardiomyopathy. We report the cases of 2 patients who presented with takotsubo cardiomyopathy and were subsequently found to have apical-variant hypertrophic cardiomyopathy, after the apical ballooning from the takotsubo cardiomyopathy had resolved. The first patient, a 43-year-old woman with a history of alcohol abuse, presented with shortness of breath, electrocardiographic and echocardiographic features consistent with takotsubo cardiomyopathy, and no significant coronary artery disease. An echocardiogram 2 weeks later revealed a normal left ventricular ejection fraction and newly apparent apical hypertrophy. The 2nd patient, a 70-year-old woman with pancreatitis, presented with chest pain, apical akinesis, and a left ventricular ejection fraction of 0.39, consistent with takotsubo cardiomyopathy. One month later, her left ventricular ejection fraction was normal; however, hypertrophy of the left ventricular apex was newly noted. To our knowledge, these are the first reported cases in which apical-variant hypertrophic cardiomyopathy was masked by apical ballooning from stress-induced cardiomyopathy.     

Recurrent Takotsubo Cardiomyopathy Related to Recurrent Thyrotoxicosis

Takotsubo cardiomyopathy, or transient left ventricular apical ballooning syndrome, is characterized by acute left ventricular dysfunction caused by transient wall-motion abnormalities of the left ventricular apex and mid ventricle in the absence of obstructive coronary artery disease. Recurrent episodes are rare but have been reported, and several cases of takotsubo cardiomyopathy have been described in the presence of hyperthyroidism. We report the case of a 55-year-old woman who had recurrent takotsubo cardiomyopathy, documented by repeat coronary angiography and evaluations of left ventricular function, in the presence of recurrent hyperthyroidism related to Graves disease. After both episodes, the patient''s left ventricular function returned to normal when her thyroid function normalized. These findings suggest a possible role of thyroid-hormone excess in the pathophysiology of some patients who have takotsubo cardiomyopathy.     

Takotsubo Cardiomyopathy

Background  Takotsubo cardiomyopathy is a novel, yet well-described, reversible cardiomyopathy triggered by profound psychological or physical stress with a female predominance. Objective  This review is designed to increase general clinician awareness about the diagnosis, incidence, pathogenesis, and therapies of this entity. Data Sources  A complete search of multiple electronic databases (Pubmed, EMBASE, Science Citation Index) was carried out to identify all full-text, English-language articles published from 1980 to the present date and relevant to this review. Review Methods  The following search terms were used: takotsubo cardiomyopathy, stress-induced cardiomyopathy, and left ventricular apical ballooning syndrome. Citation lists from identified articles were subsequently reviewed and pertinent articles were further identified. Results  Takotsubo cardiomyopathy is typically characterized by the following: 1) acute onset of ischemic-like chest pain or dyspnea, 2) transient apical and mid-ventricular regional wall-motion abnormality, 3) minor elevation of cardiac biomarkers, 4) dynamic electrocardiographic changes, and 5) the absence of epicardial coronary artery disease. The pathogenesis of the syndrome is unknown but has mostly been associated with acute emotional or physiologic stressors. Dote, Sato, Tateishi, Uchida, Ishihara (J Cardiol. 21(2):203–214, 1991); Desmet, Adriaenssens, Dens (Heart. 89(9):1027–1031, Sep., 2003); Bybee, Kara, Prasad, et al. (Ann Intern Med. 141(11):858–865, Dec 7, 2004); Sharkey, Lesser, Zenovich, et al. (Circulation. 111(4):472–479, Feb 1, 2005) The short and long-term prognosis of these patients is overwhelmingly favorable and often only requires supportive therapy. Conclusion  Whether an emotional or physical event precedes one’s symptoms, it is apparent that takotsubo cardiomyopathy case presentations mimic ST-segment elevation myocardial infarction, and thus is an important entity to be recognized by the medical community.     

Takotsubo Cardiomyopathy in a 22-Year-Old Single-Ventricle Patient

We report a highly unusual case of a 22-year-old woman with single-ventricle anatomy and a history of Fontan palliation who developed takotsubo cardiomyopathy. To our knowledge, takotsubo cardiomyopathy has not previously been described in a patient with single-ventricle anatomy, or more generally in any patient with congenital heart disease. The patient presented at our clinic for urgent examination after a 2-day history of chest pain that had begun upon the death of her dog. Invasive evaluation was refused by the patient; instead, she underwent electrocardiogram-gated coronary computed tomographic angiography, to rule out obstructive coronary disease.A physician who suspects takotsubo cardiomyopathy in a patient should look for new-onset chest pain and dyspnea coupled with these features: immediate onset of segmental akinesia in the midventricular or apical aspects of the heart, elevation of brain natriuretic peptide level 12 to 24 hours after onset of akinesia, elevation of troponin level 24 to 48 hours after onset, and disappearance of the segmental akinesia a few days after onset.     

Takotsubo cardiomyopathy in a patient with essential thrombocythemia treated with anagrelide: Case report

Takotsubo cardiomyopathy is a rare syndrome. Most often imitates acute coronary syndrome. It is characterized by transient wall motion abnormalities, especially in the apical segments of the left ventricule. Less frequently is possible to find transient akinesis or dyskinesis in the mid-ventricular segments of the left ventricule. Pathophysiological mechanisms are not completely clear. The main cause of stress cardiomyopathy is stress insult. But in rare cases can be takotsubo caused by other conditions. We reported rare case of takotsubo cardiomyopathy caused by high dose anagrelide therapy. Anagrelide is the most often used in patients with thrombocythemia. It belongs to phosphodiesterase III inhibitors and through specific pathways has certain effects on myocardium. It is the first case of takotsubo cardiomyopathy resulting from anagrelide therapy in the Czech Republic.     

Inverted Takotsubo Cardiomyopathy and the Fundamental Diagnostic Role of Echocardiography

Takotsubo cardiomyopathy is characterized by the development of transient focal wall-motion abnormalities that involve the apical and midventricular segments, in the absence of obstructive coronary artery disease. A variant, inverted takotsubo cardiomyopathy, was described in 2010. We report 3 cases in which each patient''s transthoracic echocardiogram revealed the characteristic basal and midventricular segmental akinesis of this variant. This pattern is not associated with coronary artery distribution, and it therefore can be differentiated from coronary artery disease with the use of echocardiography, by evaluating the distribution and temporal changes of akinetic areas.Key words: Cardiomyopathies/diagnosis/physiopathology, echocardiography, takotsubo cardiomyopathy/diagnosis, ventricular dysfunction, left/diagnosisTakotsubo cardiomyopathy is a syndrome characterized by transient apical and midventricular akinesis that is typically precipitated by acute stress. A variant, with akinesis of the mid and basal left ventricular (LV) segments and sparing of the apex, has been called inverted (or atypical) takotsubo cardiomyopathy. We describe 3 cases of this variant in which the transthoracic echocardiograms (TTEs) and temporal evolution of the condition were diagnostic. Each patient was emergently admitted to Barnes-Jewish Hospital in St. Louis and examined there; the TTEs were reviewed by a visiting cardiologist (AM).     

Recurrent long QT syndrome and syncope in transient apical ballooning syndrome (takotsubo cardiomyopathy)

Transient apical ballooning syndrome, or takotsubo cardiomyopathy is a syndrome characterized by reversible dilation of the left ventricular apex. It usually occurs in response to stress, and resolves completely in a few weeks. The present report describes a 55-year-old woman who presented with chest pain and syncope in response to emotional stress. Her electrocardiogram suggested acute coronary syndrome with prolonged QT. However, cardiac catheterization showed normal coronary arteries, with apical akinesis of the left ventricle. The patient’s symptoms recurred 18 months later; subsequently, she was diagnosed with recurrent takotsubo cardiomyopathy with prolonged QT and syncope. The treatment, etiology and pathophysiology of takotsubo cardiomyopathy are discussed.     

Cardiac thrombus and conduction disorder in takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a reversible form of left ventricular dysfunction with an apparently benign natural history after left ventricular recovery. Rarely there are complications such as arrhythmias and apical thrombus. We describe a case of takotsubo cardiomyopathy complicated with apical thrombus and persistent complete atrioventricular block after improvement of left ventricular wall motion.     

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.     

The first case of takotsubo cardiomyopathy associated with sodium tetradecyl sulphate sclerotherapy

The present article describes the case of a 70-year-old woman who developed a classic type takotsubo cardiomyopathy after receiving cosmetic sclerotherapy for varicose veins of the legs with sodium tetradecyl sulphate (STS) injections. The patient was in her usual state of health before the injections, and described no apprehension leading up to the procedure and no pain during the procedure. However, a few minutes after the completion of the procedure, the patient had severe chest pain of sudden onset and an electrocardiogram highly suggestive of ST elevation myocardial infarction. The patient was referred for emergent coronary angiography, which was normal. Subsequent ventriculography confirmed the suspected apical ballooning typical of takotsubo cardiomyopathy. Ventricular function returned to near-normal within three days of presentation. The present article describes what is believed to be the first case of takotsubo cardiomyopathy associated with the use of STS. A review of adverse events ascribed to STS revealed visual disturbances and transient ischemic attacks, suggesting the possibility of a common underlying vasospastic pathophysiology and an under-recognized vasoactive potential of STS that merits further investigation. In the interim, the present case advocates for the recommendation of universal pretreatment test dosing.     

Fibronectin Glomerulopathy Confused with Glomerular Endothelial Injury in a Patient with Takotsubo Cardiomyopathy

A 46-year-old woman developed takotsubo cardiomyopathy and nephrotic syndrome. The first kidney biopsy suggested non-immune-complex-mediated membranoproliferative glomerulonephritis (MPGN), and she was diagnosed with glomerular endothelial injury associated with takotsubo cardiomyopathy. A second biopsy was performed two years later because of persistent proteinuria despite renin-angiotensin system inhibition. This biopsy indicated non-immune-complex-mediated MPGN, but a mesangial and subendothelial substance of a higher electron density than that in the first biopsy was detected, suggesting the possibility of glomerular disease with non-immune deposits rather than endothelial injury. Finally, she was diagnosed with fibronectin nephropathy. Although rare, fibronectin glomerulopathy should be considered in non-immune-complex-mediated MPGN.     

The index of microcirculatory resistance (IMR) in takotsubo cardiomyopathy

We report a patient who presents with acute chest pain and positive cardiac enzymes clinically consistent with an acute coronary syndrome (ACS). Coronary angiography revealed normal epicardial arteries and the left ventriculogram was notable for apical ballooning. This was strongly suggestive of takotsubo cardiomyopathy. Pressure wire measurements of Fractional flow reserve (FFR) and IMR demonstrated a normal FFR, but significant microcirculatory dysfunction. This is the first such case that documents this abnormality invasively using the IMR, which unlike CFR is specific for the microcirculation and reproducible through a range of hemodynamic states. © 2010 Wiley‐Liss, Inc.     

A case of recurrent earthquake stress cardiomyopathy with a differing wall motion abnormality

We present the case of a Caucasian woman who survived two major earthquakes, presenting on each occasion with stress cardiomyopathy, but with a different pattern of regional wall motion abnormality on the second occasion. The first Christchurch earthquake struck on September 4, 2010. At 7.1 on the Richter scale, it was larger than the major Haiti quake, but miraculously there were no direct fatalities. In the week following, eight women meeting modified Mayo criteria for stress cardiomyopathy presented to Christchurch Hospital. The second Christchurch earthquake was on February 22, 2011. It measured 6.4 on the Richter scale and caused 180 direct fatalities. In the week following this earthquake, 24 women were admitted with stress cardiomyopathy. One patient presented after both earthquakes. This 76-year-old woman first presented on September 4 with 10 hours of chest pain. Electrocardiogram showed inferolateral deep T-wave inversion and QT prolongation. TnI peaked at 0.81 μg/L. Coronary angiography demonstrated diffuse atheroma with a moderate mid LAD lesion that was stented at the time. Echocardiography showed a classic takotsubo pattern. Her follow-up echocardiogram on September 28 was normal and she was completely well at that point. However, during the second earthquake of February 22, she again developed chest pain and shortness of breath. TnI peaked at 1.3 μg/L. Echocardiogram showed a midwall variant takotsubo with apical sparing. She was discharged from hospital on the 25th, planning to leave Christchurch for a new home in another city, but returned for follow-up echocardiogram on July 27. This was normal.     

Inverted takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a transient acute left ventricular dysfunction characterized by left ventricular apical akinesis and ballooning without obstructive coronary disease described predominantly in post-menopausal women in the setting of acute emotional or physical stress. Recent reports have described isolated transient basal akinesis (inverted takotsubo cardiomyopathy) in mostly female patients with acute neurologic disorders or pheochromocytoma. We describe a rare case of a 78-year-old male with inverted takotsubo cardiomyopathy in the setting of acute abdominal pain attributed to biliary colic. A review of published literature reveals that inverted takotsubo cardiomyopathy precipitated by acute stress rather than an acute neurologic disorder appears to be an extremely rare presentation in a male patient. We discuss the relevant literature regarding incidence and reported gender distribution of inverted takotsubo cardiomyopathy.     

Recurrent takotsubo with prolonged QT and torsade de pointes and left ventricular thrombus

Takotsubo cardiomyopathy, also known as “takotsubo syndrome,” refers to transient apical ballooning syndrome, stress cardiomyopathy, or broken heart syndrome and is a recently recognized syndrome typically characterized by transient and reversible left ventricular dysfunction that develops in the setting of acute severe emotional or physical stress. Increased catecholamine levels have been proposed to play a central role in the pathogenesis of the disease, although the specific pathophysiology of this condition remains to be fully determined. At present, there have been very few reports of recurrent takotsubo cardiomyopathy. In this case report, we present a patient with multiple recurrences of takotsubo syndrome triggered by severe emotional stress that presented with recurrent loss of consciousness, QT prolongation, and polymorphic ventricular tachycardia (torsade de pointes) and left ventricular apical thrombus.     

Transient Reverse Takotsubo Cardiomyopathy Following a Spider Bite in Greece: A Case Report

Black widow spider is endemic in the Mediterranean area and although envenomations are rare, may occasionally lead to death.We present a case of a 64-year-old female developing a rare variant of takotsubo, stress-induced, cardiomyopathy after a spider bite. This resulted in acute heart failure within 24 hours of the bite. With medical treatment and supportive care, the patient''s clinical condition improved.Reverse takotsubo cardiomyopathy was diagnosed by echocardiography, which was transient. Clinical and echocardiographic findings have been completely resolved on follow-up 46 days later.Reverse takotsubo cardiomyopathy has not been yet described following a spider bite. Doctors in the emergency department of endemic countries should be familiar with this potential complication.     

Apical Thrombus Associated with Takotsubo Cardiomyopathy in a Young Woman

We report a case of Takotsubo cardiomyopathy complicated by left ventricular apical thrombus in a young woman; the thrombus and wall motion abnormalities disappeared after 3 weeks of anticoagulant therapy. These findings suggest that appropriate anticoagulation therapy should be performed in patients with Takotsubo cardiomyopathy until wall motion abnormalities improve .     

Pathophysiology of the Syndrome: Biventricular Takotsubo Cardiomyopathy: Case Study and Review of Literature

Biventricular takotsubo cardiomyopathy is associated with more hemodynamic instability than is isolated left ventricular takotsubo cardiomyopathy; medical management is more invasive and the course of hospitalization is longer.In March 2011, a 62-year-old woman presented at our emergency department with abdominal pain, nausea, and vomiting. On hospital day 2, she experienced chest pain. An electrocardiogram and cardiac enzyme levels suggested an acute myocardial infarction. She underwent cardiac angiography and was found to have severe left ventricular systolic dysfunction involving the mid and apical segments, which resulted in a left ventricular ejection fraction of 0.10 to 0.15 in the absence of obstructive coronary artery disease. Her hospital course was complicated by cardiogenic shock that required hemodynamic support with an intra-aortic balloon pump and dobutamine. A transthoracic echocardiogram revealed akinesis of the mid-to-distal segments of the left ventricle and mid-to-apical dyskinesis of the right ventricular free wall characteristic of biventricular takotsubo cardiomyopathy. After several days of medical management, the patient was discharged from the hospital in stable condition.To the best of our knowledge, this is the first review of the literature on biventricular takotsubo cardiomyopathy that compares its hemodynamic instability and medical management requirements with those of isolated left ventricular takotsubo cardiomyopathy. Herein, we discuss the case of our patient, review the pertinent medical literature, and convey the prevalence and importance of right ventricular involvement in patients with takotsubo cardiomyopathy.Key words: Cardiomyopathies/radiography, hemodynamic instability/takotsubo, magnetic resonance angiography, takotsubo cardiomyopathy, biventricular/diagnosis, transient apical ballooning syndrome, ventricular dysfunction, left, ventricular dysfunction, rightTransient left ventricular apical ballooning syndrome (TLVABS) is an acute cardiac syndrome that typically is characterized by transient left ventricular (LV) wall-motion abnormalities, electrocardiographic (ECG) findings of ST-T segment changes, and minimal release of cardiac enzymes in the absence of significant stenosis of the coronary arteries (<50% luminal stenosis).^1–8 This syndrome was first described in Japan in 1991 and named takotsubo-like LV dysfunction in reference to the asynergy, which consists of hypokinesis or akinesis of the mid-to-apical LV and hyperkinesis of the basal LV extending over more than one coronary artery region.^8–11 Since then, this asynergy has been called takotsubo cardiomyopathy (TC), stress cardiomyopathy, ampulla syndrome, broken-heart syndrome, and neurogenic stunned myocardium.^12–14 Takotsubo cardiomyopathy presents clinically with chest pain and dyspnea associated with ECG changes, thereby mimicking ST-segment elevation myocardial infarction that is often preceded by emotional or physical stress.^1-7,9,10 Indeed ST-segment elevation is the most common ECG abnormality, reported in approximately 82% of patients with TC, followed by T-wave inversion in 64%.^8,15 This peculiar cardiac syndrome results in severe impairment of systolic function.There are several variants of TC. Isolated LV involvement is the most common variant, but right ventricular (RV) involvement is gaining increased recognition. Although there is only one documented case of isolated RV stress cardiomyopathy,¹⁶ the recognition of biventricular TC is increasing. It has been reported that RV involvement affects approximately 25% to 42% of patients diagnosed with TC.^12,13,17,18 In addition to isolated LV, isolated RV, and biventricular involvement, a variety of ballooning patterns has been observed. The typical apical-ballooning shape, with akinesis of the apical and mid-ventricular LV segments, is the most common; however, a mid-ventricular variant with apical sparing and a variant with isolated basal ballooning have been recognized.¹⁸ Left ventricular systolic dysfunction and heart failure—with simultaneous RV dysfunction—identifies a patient population with an extremely poor prognosis.¹⁹ Therefore, it is not surprising that TC with RV involvement appears to be associated with more severe LV dysfunction that results in significantly longer hospitalization and hemodynamic instability that is associated with a worse prognosis.^1-4,13,18 Clinicians need to be aware of the prevalence and complications of RV involvement and dysfunction, because it can affect patient management, morbidity, and, ultimately, mortality rates in substantial ways.The data concerning RV involvement in TC are sparse, because they are derived from several case reports and case series studies. This review of the literature documents the prevalence, pathophysiology, diagnostic imaging characteristics, clinical findings, management, and prognosis of patients with biventricular TC. Throughout this article, TC with RV involvement will be referred to as biventricular TC, whereas classic left ventricular TC (with apical ballooning) will be referred to as TLVABS. All of the documented cases of biventricular TC have been evaluated and analyzed in regard to how the patient presented, how the TC was diagnosed and managed, and how we can improve in managing the even more hemodynamically unstable biventricular TC, in comparison with TLVABS.