Takotsubo cardiomyopathy manifesting as no reflow pattern in coronary flow by transthoracic Doppler echocardiography and prolonged recovery of regional left ventricular wall motion abnormality: a case report

A 80-year-old woman was admitted to our hospital because of chest pain. Electrocardiography revealed ST segment elevation in the I, aVL, and V1-V5 leads. Echocardiography revealed left ventricular apical aneurysmal change with ejection fraction of 31%. Coronary angiography showed no abnormalities. Creatine kinase was not elevated in her clinical course. The diagnosis was takotsubo cardiomyopathy. Transthoracic Doppler echocardiography was performed on the 2nd hospital day. Coronary flow velocity pattern in the left anterior descending artery revealed shortened diastolic deceleration time (108 msec) and systolic retrograde flow. Asynergy of the left ventricle gradually improved, but still persisted slightly at 6 months after discharge. Most patients with takotsubo cardiomyopathy have normal coronary flow velocity pattern in the acute phase. In this case, no reflow pattern of coronary flow was observed during prolonged recovery from left ventricular regional wall motion abnormality.     

Survival after acute necrotizing eosinophilic myocarditis complicating a massive left ventricular mural thrombus: a case report

An 81-year-old man was referred to our hospital with exertional dyspnea following cold-like symptoms. Electrocardiography revealed ST elevation and positive T wave in leads I, II, aVL, aVF, and V2-V6. The diagnosis was acute myocarditis complicating heart failure. He was conservatively managed. On hospital day 8, brain infarction developed and echocardiography disclosed massive mural thrombus in the left ventricle. Left ventriculotomy was performed on hospital day 21 and histological examination showed inflammatory cell infiltration mainly composed of eosinophils and monocytes, degeneration of myocytes with replacement fibrosis, and fresh fibrin thrombus overlaying the endocardium. These findings were compatible with a diagnosis of acute necrotizing eosinophilic myocarditis(ANEM). He recovered uneventfully without specific therapy. This case suggests that a subtype of ANEM might be self-limiting.     

Tako-tsubo cardiomyopathy associated with brain metastasis of seminoma in a patient with chronic kidney disease

We report a case of tako-tsubo cardiomyopathy associated with brain metastasis of seminoma. This disease is characterized by transient cardiac wall motion abnormalities, electrocardiographic changes and minimal myocardial enzymatic release. During the hospital days, acute congestive heart failure suddenly appeared. The electrocardiogram showed a ST segment elevation in V1-3 and a giant negative T wave in I, aVL, aVF and V3-6. The echocardiogram revealed left ventricular dysfunction with severe hypokinesis to akinesis of anterior and apical wall regions, and hyperkinesis of the basal wall despite the lack of cardiac enzymatic abnormalities. With proper treatment, the patient's overall condition, wall motion and electrocardiographic abnormalities greatly improved.     

Variant angina induced by biliary colic

A 65 year old woman with gall stones presented with crushing chest pain after an attack of biliary colic. The electrocardiogram showed ST segment elevation in leads I, aVL, and V1-V3 while leads II, III, and aVF showed ST segment depression. Cardiac enzyme activity remained within the normal range. During the next three weeks attacks of epigastric and right hypochondrial pain preceded by crushing chest pain with identical electrocardiogram changes occurred with decreasing frequency. Coronary arteriography showed 60% obstruction of the left anterior descending coronary artery and good left ventricular function. During the next three years the patient complained both of mild abdominal pain, probably biliary colic, and mild effort related angina pectoris without a relation between the two symptoms. It is suggested that the attack of variant angina was triggered by biliary colic through sympathoadrenal discharge causing vasospasm.     

Variant angina induced by biliary colic.

A 65 year old woman with gall stones presented with crushing chest pain after an attack of biliary colic. The electrocardiogram showed ST segment elevation in leads I, aVL, and V1-V3 while leads II, III, and aVF showed ST segment depression. Cardiac enzyme activity remained within the normal range. During the next three weeks attacks of epigastric and right hypochondrial pain preceded by crushing chest pain with identical electrocardiogram changes occurred with decreasing frequency. Coronary arteriography showed 60% obstruction of the left anterior descending coronary artery and good left ventricular function. During the next three years the patient complained both of mild abdominal pain, probably biliary colic, and mild effort related angina pectoris without a relation between the two symptoms. It is suggested that the attack of variant angina was triggered by biliary colic through sympathoadrenal discharge causing vasospasm.     

Cardiac rupture and admission electrocardiography in acute anterior myocardial infarction: implication of ST elevation in aVL

This study determines the usefulness of electrocardiography in the emergency room for assessing the risk of cardiac rupture after acute anterior myocardial infarction (MI). The presence of ST segment elevation on the admission 12-lead electrocardiography was evaluated in 325 consecutive anterior MI patients. A forward-stepwise logistic regression analysis for cardiac rupture was performed with the covariates of age, gender, hypertension, history of MI, reperfusion therapy by coronary angioplasty, and ST segment elevations in leads I, aVL, V1-V6. Cardiac rupture occurred in 16 patients, including 7 with left ventricular free wall rupture (FWR) and 9 with ventricular septal perforation (VSP). For FWR, ST elevation in lead aVL was the only independent predictor (odds ratio = 12.1, P = .0215). For VSP, female gender (odds ratio = 5.32, P = .0201) was the independent predictor. In conclusion, in patients with acute anterior MI, ST segment elevation in lead aVL on the admission electrocardiography is a significant risk factor for left ventricular FWR.     

Diagnostic Value of aVL Derivation for Right Ventricular Involvement in Patients with Acute Inferior Myocardial Infarction

Background: Right ventricular (RV) involvement is associated with increased morbidity and mortality in patients with acute inferior myocardial infarction (MI). Although electrocardiography is probably the most useful, simple, and objective tool for the diagnosis of acute MI, there are no well‐defined criteria in the standard 12‐lead electrocardiogram to properly identify RV involvement in patients with acute inferior MI. Our objective was to evaluate the value of ST‐segment depression in lead aVL in diagnosing RV involvement in patients with acute inferior MI. Materials and Methods: Sixty‐seven patients, hospitalized with acute inferior myocardial infarction, were included in this study. The diagnosis of acute inferior myocardial infarction was based on the clinical history, characteristic enzyme pattern of CK‐MB values, and the appearance of ST‐segment elevation ≥ 1 mm in at least two of the leads (leads II, III, aVF). RV infarction was defined by ST‐segment elevation ≥ 1mm in lead V4R. ST‐segment depression in lead aVL that is more than 1 mm was accepted as a diagnostic criterion for RV involvement in patients with acute inferior MI. Results: Thirty‐one patients had >1 mm ST‐segment depression and 28 of them had right ventricular infarction according to lead V4R. Thirthy‐six patients showed ≤1 mm ST‐segment depression indicating no right ventricular involvement but four of them also had right ventricular infarction according to V4R. Conclusion: More than 1 mm ST‐segment depression in lead aVL was found to have high sensitivity (87%), specificity (91%), high positive and negative predictive value (90%, 88%, respectively), and high diagnostic accuracy (89%) in diagnosing RV involvement in patients with acute inferior MI. Therefore, by using a simple 12‐lead electrocardiographic sign, ST‐segment depression >1 mm in lead aVL, obtained on admission, it is possible to identify RV involvement in patients with acute inferior MI.     

Assessment of the time course of stunned myocardium with cardiac magnetic resonance imaging: a case report

A 77-year-old woman with chest pain was admitted to our hospital for evaluation and treatment. Electrocardiography showed T-wave inversion in the I, aVL and V2-V6 leads. Emergency coronary angiography showed 75% stenosis in the left anterior descending artery. Left ventriculography demonstrated akinesis of the left ventricular apical region. Iodine-123-beta-methyl-p-iodophenyl-pentadecanoic acid radioactive isotope imaging showed an uptake defect in the apical region during the acute phase, but the defect disappeared 1 month later. Cine cardiac magnetic resonance (CMR) in the acute phase showed apical akinesis and hyperkinesis of the mid region, as observed by left ventriculography. Contrast magnetic resonance imaging with gadolinium showed no delayed hyperenhancement. One month later, cine CMR showed disappearance of the abnormal wall motion and contrast magnetic resonance imaging demonstrated no delayed hyperenhancement. CMR is useful to monitor changes in wall motion and wall thickening in the stunned myocardium.     

Angiographic correlates of anterior ST segment depression in acute inferior wall myocardial infarction.

This study was conducted prospectively to assess the correlation between the pattern of anterior ST segment depression on the admission electrocardiogram and the in-hospital morbidity and mortality in patients with acute inferior wall myocardial infarction. Coronary angiography was also done to assess its correlation, if any, with pattern of anterior ST segment depression. Our study cohort comprised of 165 consecutive patients with acute inferior wall myocardial infarction divided into four groups based on admission electrocardiogram. Group I (n = 33): patients with no anterior ST segment depression; group II (n = 16): patients with ST segment depression in leads V1-V3; group III (n = 71): patients with ST segment depression in leads V4-V6, I and aVF, and; group IV (n = 45): patients with ST segment depression in all anterior leads (V1-V6, I, aVL). The outcomes were analysed in terms of high grade atrioventricular block, Killip class II or higher failure, and in-hospital mortality. Coronary angiography was performed to analyse coronary anatomy. Group IV patients had increased incidence of complete heart block (37.8% vs 15.2% in the total group) (p < 0.001) and increased mortality (11.1% vs 4.2% in the total group) (p < 0.05). This group also had greater incidence of triple vessel disease (76.7%) (p < 0.001). Group II patients had greater incidence of double vessel disease (88.9%) (p < 0.05) and had no triple vessel disease. Group III patients had double vessel disease (76.5%) (p < 0.05) or triple vessel disease (23.5%) (p = NS) and no single vessel disease. Coronary angiography in group II showed greater incidence of involvement of left circumflex artery and right coronary artery while in group III there was left anterior descending artery and right coronary artery disease. We conclude that patients with anterior ST segment depression in group III and group IV categories are in high risk subset with acute inferior wall myocardial infarction.     

Extensive myocardial stunning showing transient regression of prolonged T wave inversion and prolonged sympathetic denervation

A 69-year-old woman was admitted to the hospital with palpitations. Although left ventriculography showed extensive akinesis except in the basal hyperkinetic segment, coronary angiography showed normal coronary arteries. 123I-metaiodobenzylguanidine (MIBG) accumulation was obviously reduced in the anteroseptal, apical and inferior areas. Inverted T waves developed on day 3 and disappeared on day 104 after transient regression. Echocardiography showed normal left ventricular motion two weeks later. Ergonovine provocation test showed no vasospasm and thallium-201 showed no perfusion defect on day 46. Electrocardiography and MIBG returned to normal on day 216. These findings suggest prolonged sympathetic nerve injury in extensive myocardial stunning.     

Global myocardial ischemia as a complication of an acute type A aortic dissection--rapid diagnosis of a case by transesophageal echocardiography

A 36-year-old female was admitted for severe chest pain followed by profound shock. Electrocardiography showed severe ST segment depression (0.5-0.7 mV) in all leads except aVR and aVL. Echocardiography revealed an intimal flap in the ascending aorta and coexisting grade 3 aortic regurgitation. She was immediately intubated and transferred to the intensive care unit. Transesophageal echocardiography (TEE) demonstrated an intimal tear at 2 cm above the sinotubular junction, and the ostium of the left main trunk was oppressed by the intimal flap during diastole. Emergency graft replacement of the ascending aorta and aortic hemiarch concomitant with aortic valve resuspension was performed successfully. The ECG changes reversed to normal immediately after the operation. The patient was extubated 2 days postoperatively and discharged from the hospital 14 days postoperatively. TEE is useful for the rapid evaluation of coronary malperfusion as a complication of acute aortic dissection, especially in patients with hemodynamic instability.     

Digital subtraction angiography and Fourier analysis of the left ventriculography: new methods of analyzing left ventricular function

To evaluate two new methods of analyzing left ventricular function, digital subtraction left ventriculography (DSLV) and Fourier analysis of left ventriculography (FALV) were performed after conventional left ventriculography (LV) in 17 consecutive catheterized cases. Ejection fraction of FALV and LV corresponded closely with the correlation coefficient of 0.906, while segmental wall motion corresponded less with the range of correlation coefficients from 0.56 for the apical segment to 0.94 for the anterior wall. In 10 cases with asynergic segments of the left ventricle, Fourier analysis showed less hypokinesis in four (all had hypokinesis at the septal segment), the same degree in five and more in one case, suggesting the possibility of FALV to evaluate three-dimensional left ventricular function in a single projection.     

Repeated changes of electrocardiogram caused by Takotsubo-type cardiomyopathy: a case with hypertrophic nonobstructive cardiomyopathy

A 67-year-old woman had been examined due to abnormalities on electrocardiography (ECG) at a medical checkup three years previously. When a negative T-wave was seen in leads I, aVL, and V1 to V4, but the abnormal findings were improved at consultation. Echocardiography revealed apical hypertrophy and hypertrophic nonobstructive cardiomyopathy was diagnosed. She felt chest discomfort in September, 2003 and an ECG showed a negative T-wave in leads I, II, III aVL, aVF and V2 to V6 and an elongation of QT interval Left ventriculography revealed myocardial hypertrophy at the left ventricular apex and left ventriclar wall motion was normal. Coronary angiography did not show any significant luminal narrowing. I-123 metaiodobenzyl-guanitidine scintigraphy showed marked perfusion defects at the left ventricular apex. After five months, ECG showed an improvement of the QT interval and a decrease in the negative T-wave. We considered that the repeated changes of ECG were caused by Takotsubo-type cardiomyopathy.     

A Mid-Ventricular Variant of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TC) was initially recognized in Japan in 1990. The typical patient is a postmenopausal woman with symptoms that mimic an acute coronary syndrome generally following physical or emotional stress. The EKG will typically have dynamic ST segment changes, while the angiogram will usually show normal coronary arteries. In classic TC, the left ventriculogram typically shows akinesis and ballooning of the apex with a normal or hyperdynamic base. Several variants of TC have been described. In this case report, we describe a midventricular variant of TC in a 64-year-old Hispanic female. The patient had chest pain, shortness of breath, elevated cardiac enzymes, and ST-segment elevations in leads II, aVF, and V5-V6. Coronary angiography revealed normal coronary arteries. Left ventriculogram showed hypokinesis of the midventricular segment and hyperdynamic apical and basal regions. Although the exact mechanism of TC is unknown, several theories include loss of estrogen, catecholamine or neurohumoral stimulation, coronary artery spasm, and left ventricular outflow tract (LVOT) obstruction.     

Pheochromocytoma with reversal of tako-tsubo-like transient left ventricular dysfunction: a case report

A 59-year-old male was admitted to the emergency department because of sustained chest oppression. Electrocardiography revealed J type ST depression and peaked T wave in leads II, III, aVF, and V4-V6. No stenosis was found in the coronary arteries by urgent coronary angiography. Left ventricular abnormal wall movement with akinesis in the base and hyperkinesis in the apical area was observed and improved on the 12th day. Myocardial scintigraphy with iodine-123-metaiodobenzylguanidine showed completely defective images and decreased accumulation in the base with combined thallium-201 and iodine-123-beta-methyl-p-iodophenyl-pentadecanoic acid. Myocardial biopsy on the 12th day disclosed contraction band necrosis. The diagnosis was catecholamine-induced cardiomyopathy caused by pheochromocytoma.     

Acute myocarditis with localized left ventricular aneurysm: a report of three cases

Ventricular aneurysms are rarely observed in viral myocarditis. Three cases whose left ventriculograms showed localized left ventricular aneurysms in the chronic phase of myocarditis are reported. The etiology in one case was herpes simplex virus (Case 1). Two cases (Case 2, 3) of myocarditis were admitted to our Coronary Care Unit in the acute phase, when diffuse hypokinesis of the left ventricle was demonstrated by two-dimensional (2-D) echocardiography. Hypokineses progressed to localized left ventricular aneurysm formation, demonstrated by cine angiography. In the acute phase, ST segment elevation was observed in these two cases, but it resolved. Abnormal Q waves also resolved in the chronic phase. Negative T waves were nearly normalized in one of them (Case 3). Abnormal Q waves with ST segment depression were observed in another case (Case 1). Thus, there were no characteristic or consistent findings suggesting a left ventricular aneurysm on electrocardiography. 2-D echocardiography and cine angiography proved useful for diagnosing this uncommon complication. Long-term follow-up of these cases will be important, because viral myocarditis can develop into dilated cardiomyopathy. The mechanism of left ventricular aneurysm following acute viral myocarditis included: (1) direct viral injury of the myocardium, (2) localized injury due to immunological mechanisms, and (3) coronary thrombosis due to increased platelet aggregation by viral infection.     

R wave amplitude changes during stress testing. Comparison with ST segment depression and angiographic correlation

One-hundred and seven exercise stress tests and coronary angiograms were reviewed retrospectively, in order to evaluate the usefulness of R wave amplitude changes (ΔR) during exercise compared with ST segment depression in the screening of patients with coronary artery disease (CAD).We also attempted to correlate ΔR with the severity of CAD as expressed by coronary arteriography and left ventriculography.Thirty-six patients showed no coronary artery narrowing (0-V); the remaining 71 patients with stenosis of 70% of at least one of the major coronary arteries were divided into three groups.Sixteen patients had single vessel disease (1-V); five (31%) in this group showed abnormal left ventricular wall motion. Thirty-one patients had two-vessel disease (2-V); 22 (71%) of the 31 demonstrated abnormal left ventricular wall motion. Twenty-four patients had three-vessel disease (3-V); 20 (83%) of the 24 showed abnormal left ventricular wall motion.We considered ΔR values ≥ 0 and ST segment depression ≥ 1 mm. significant for diagnosis of CAD.The sensitivity of the ΔR method in predicting CAD was superior to the method based upon ST segment depression; however, the latter was significantly (P < .02) more specific than the former. The predictive accuracy of these two criteria was similar.We found ΔR values ≥ 0 more frequently in the 2-V and 3-V groups as compared with the 1-V group. Patients of the 2-V and 3-V groups had a significantly higher incidence of abnormal left ventricular wall motion (P < .01, P < .0002, respectively) in comparison with 1-V patients. Thus, ΔR values ≥ 0 during exercise stress testing are very likely related to left ventricular impairment.Even though the accuracy of the ΔR method was greater in more severe CAD, it seems to be offset by a concomitant decrease in specificity.     

心肌梗塞合并室壁瘤患者心功能的评价

对29例心肌梗塞合并室壁瘤和38例未合并室壁瘤病人的二维超声心动图、心电图、X线胸片和临床心功能的对照分析结果表明:(1)室壁瘤组与无室壁瘤组,临床心功能≥Ⅱ级者分别占90％与55％,EF值分别为43Z±12％与65±11％(P<0.01),表明心功能不全是室壁瘤病人常见的并发症;(2)EF值与QRS记分、壁瘤范围均呈负相关,r分别=-0.42及-0.59(P分别<0.01及<0.005),且壁瘤范围又与ORS记分呈正相关,r=0.33(P<0.05),说明梗塞面积大,壁瘤范围亦大,而心功能则差;(3)EF值与抬高的ST段≥2mm的导联数或∑ST未显示明显的关系。     

Female carrier of Duchenne muscular dystrophy presenting with secondary dilated cardiomyopathy: a case report

A 48-year-old female carrier of Duchenne muscular dystrophy had developed congestive heart failure but had no skeletal muscle symptoms. She was admitted to our hospital complaining of palpitation in December 1998. Her three sons had Duchenne muscular dystrophy. Neurological examination was unremarkable with no evidence of muscle weakness. Serum creatine kinase level was slightly increased. Echocardiography showed severe left ventricular dysfunction. Coronary angiography showed no abnormalities. Left ventriculography showed generalized hypokinesis and left ventricular ejection fraction was 28%. Dystrophin immunostaining of the skeletal muscle biopsy specimen showed a mosaic pattern. The dystrophin negative fibers were scattered among positive fibers. Cardiomyopathy is the only clinical manifestation of dystrophin gene mutation in carriers. Beta-blocker therapy(carvedilol 5 mg/day) was effective in this patient.     

Inaccuracy of various proposed electrocardiographic criteria in the diagnosis of apical myocardial infarction--a critical review

The diagnostic accuracy of the standard electrocardiogram (ECG) in apical myocardial infarction (MI) was evaluated in 112 consecutive patients with recent MI and wall-motion abnormalities limited to the left ventricular (LV) apex on two-dimensional echocardiography, performed at rest 21 to 84 days after MI. The following patterns of abnormal (greater than or equal to 30 ms) Q waves were found: anteroseptal (Q V1-V4) in 44 patients (39.3%), anterolateral (Q V1-V6 and/or I, aVL) in 22 (19.6%), inferior (Q III, aVF or II, III, aVF) in five (4.5%), lateral (Q I, aVL and/or V5-V6) in five (4.5%), anteroinferior in six (5.3%); non-Q MI was present in 30 patients (26.8%). By applying various proposed ECG criteria, the presence of apical MI was correctly identified in very few (24, 21%) patients. LV apex was extensively asynergic in 85 patients (76%) and partially asynergic in 27 (24%). All the patients with Q waves in lateral leads and 47% of the patients with non-Q MI had partially asynergic LV apex, while in the other ECG patterns, extensively asynergic LV apex was predominant. The presence of both greater than or equal to 30 ms Q waves and loss of R in left precordial leads and I strongly suggests extensive apical asynergy; normal QRS in the same leads, however, does not exclude extensive apical involvement.(ABSTRACT TRUNCATED AT 250 WORDS)