Transient left ventricular outflow tract obstruction with systolic anterior motion of the mitral valve: A stunning cause

Left ventricular outflow tract obstruction (LVOTO) and systolic anterior motion (SAM) of the mitral valve may have various etiologies, of which hypertrophic cardiomyopathy is the most common. More rarely, an acute coronary syndrome, myocardial stunning, and takotsubo cardiomyopathy may give rise to LVOTO and SAM. Here, we present a 70‐year‐old female patient with a non‐ST‐elevation acute coronary syndrome treated with percutaneous coronary intervention. Echocardiography the day after, because of dyspnea and hypotension, revealed apical akinesia, LVOTO, and SAM, which proved completely reversible after treatment with a β‐blocker and a 2‐month follow‐up period. It was concluded that postischemic apical stunning had caused LVOTO and SAM.     

Myocardial infarction with non-obstructive coronary arteries: A comprehensive review and future research directions

Acute coronary syndromes constitute a variety of myocardial injury presentations that include a subset of patients presenting with myocardial infarction with non-obstructive coronary arteries(MINOCA). This acute coronary syndrome differs from type 1 myocardial infarction(MI) regarding patient characteristics, presentation, physiopathology, management, treatment, and prognosis. Two-thirds of MINOCA subjects present ST-segment elevation;MINOCA patients are younger, are more often female and tend to have fewer cardiovascular risk factors. Moreover, MINOCA is a working diagnosis, and defining the aetiologic mechanism is relevant because it affects patient care and prognosis. In the absence of relevant coronary artery disease, myocardial ischaemia might be triggered by an acute event in epicardial coronary arteries,coronary microcirculation, or both. Epicardial causes of MINOCA include coronary plaque disruption, coronary dissection, and coronary spasm.Microvascular MINOCA mechanisms involve microvascular coronary spasm,takotsubo syndrome(TTS), myocarditis, and coronary thromboembolism.Coronary angiography with non-significant coronary stenosis and left ventriculography are first-line tests in the differential study of MINOCA patients.The diagnostic arsenal includes invasive and non-invasive techniques. Medical history and echocardiography can help indicate vasospasm or thrombosis, if one finite coronary territory is affected, or specify TTS if apical ballooning is present.Intravascular ultrasound, optical coherence tomography, and provocative testing are encouraged. Cardiac magnetic resonance is a cornerstone in myocarditis diagnosis. MINOCA is not a benign diagnosis, and its polymorphic forms differ in prognosis. MINOCA care varies across centres, and future multi-centre clinical trials with standardized criteria may have a positive impact on defining optimal cardiovascular care for MINOCA patients.     

Prevalence of stress-induced myocardial stunning (Tako-Tsubo cardiomyopathy) among patients undergoing emergency coronary angiography for suspected acute myocardial infarction

Stress-induced myocardial stunning is defined as a syndrome of acute chest pain, ST-T changes on the ECG and transient left ventricular apical wall motion abnormalities mimicking acute myocardial infarction but with surprisingly normal coronary angiography findings.

The aim of this retrospective study is to assess the prevalence of stress-induced myocardial stunning among patients undergoing urgent coronary angiography for suspected acute myocardial infarction.

During a four-year period (2002–2005), a total of 5876 patients underwent urgent coronary angiography for suspected acute myocardial infarction at three tertiary centers. Four patients fulfilled the diagnostic criteria for stress-induced myocardial stunning. Thus, the cath-lab prevalence of stress-induced myocardial stunning (i.e. among patients undergoing urgent coronary angiography for suspected acute myocardial infarction) was estimated as 1 per 1469 ST-elevation coronary angiograms (i.e. 0.07%) The estimated annual population incidence of this rare disorder was calculated as 0.00006%.

Stress-induced myocardial stunning is an extremely rare syndrome among patients undergoing emergency coronary angiography for suspected acute myocardial infarction.     

It’s a Trap! Clinical Similarities and Subtle ECG Differences between Takotsubo Cardiomyopathy and Myocardial Infarction

We describe a 65-year-old woman with a history of hypertension and smoking who presented with an acute episode of chest pain precipitated by severe emotional stress. Her initial electrocardiogram done in the emergency room showed non-specific T wave changes in the lateral leads and her cardiac troponin levels were mildly elevated. Because of her clinical presentation, she was admitted with a presumptive diagnosis of acute myocardial infarction and managed with antiplatelet and anticoagulant therapy. Coronary angiogram did not reveal coronary artery disease and left ventriculography showed findings consistent with apical ballooning syndrome or takotsubo cardiomyopathy. Subsequent electrocardiograms displayed dramatic changes including T wave inversions, QT interval prolongation and U waves. The patient remained asymptomatic and recovered uneventfully. Three weeks post-discharge, an echocardiogram documented resolved left ventricular dysfunction. We describe the clinical features and highlight the electrocardiographic findings that may help differentiate takotsubo cardiomyopathy from myocardial infarction.     

Myocardial infarction with non-obstructive coronary arteries (MINOCA): Intracoronary imaging-based diagnosis and management

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is defined by clinical evidence of myocardial infarction (MI) with normal or near-normal coronary arteries on angiography. This condition is present in about 5% to 25% of patients presenting with acute coronary syndromes. MINOCA is a working diagnosis. Current guidelines and consensus recommend identification of underlying causes of MINOCA in order to optimize treatment, improve prognosis, and promote prevention of recurrent myocardial infarction. An accurate evaluation of patient history, symptoms and use of invasive and non-invasive imaging should lead to identification of epicardial or microvascular causes of MINOCA and differentiation from non-ischemic myocardial injury due to both cardiac (e.g. myocarditis) and non-cardiac disease (e.g. pulmonary embolism).In this review, we highlight the role of coronary imaging in differential diagnosis of patients presenting with MINOCA. Intravascular ultrasound and optical coherence tomography are well known technologies used in different settings from acute to chronic coronary syndromes. In MINOCA patients, coronary imaging could help to identify pathological alterations of the epicardial vessels that are not visible by coronary angiography such as plaque disruption, coronary dissection, coronary thromboembolism, coronary spasm, and coronary artery disease in patients presenting with takotsubo syndrome. In future, the widespread use of these technologies, in the right clinical context, could lead to optimization and personalization of treatment, and to better prognosis of patients presenting with MINOCA.     

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.     

Hyponatremia--an unusual trigger of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is an acute cardiac entity with clinical manifestations similar to myocardial infarction, accounting for 1-2% of acute coronary syndrome admissions. Its underlying pathophysiology is not yet well established. It is usually associated with acute physical or emotional stress, but the list of potential triggers has grown as the condition attracts the attention of the medical community. In order to diagnose the condition correctly and to gain new insights into it, we need to know its potential triggers as well as its clinical presentation and diagnostic criteria. We report a case of takotsubo cardiomyopathy triggered by hyponatremia.     

Spontaneous coronary artery dissection and takotsubo syndrome: The chicken or the egg causality dilemma

Acute coronary syndrome (ACS) including spontaneous coronary artery dissection (SCAD) has been reported to trigger its own clinical twin takotsubo syndrome (TS). The pathogenetic association between SCAD and TS remains to be elucidated. The two diseases afflict predominantly women and both conditions may be triggered by an emotional stress factor and an unusual extreme physical exercise. Herein, we describe a case of 54‐year‐old woman presenting with ACS caused by an obtuso‐marginal SCAD. Concurrently, the patient had typical clinical features and course of mid‐apical pattern of TS. The causal link between the two conditions is discussed. © 2017 Wiley Periodicals, Inc.     

Current interpretation of myocardial stunning

Myocardial stunning is a temporary post-ischemic cardiac mechanical dysfunction. As such, it is a heterogeneous entity and different conditions can promote its occurrence. Transient coronary occlusion, increased production of catecholamines and endothelin, and myocardial inflammation are all possible causes of myocardial stunning. Possible underlying mechanisms include an oxyradical hypothesis, calcium overload, decreased responsiveness of myofilaments to calcium, and excitation-contraction uncoupling due to sarcoplasmic reticulum dysfunction. The aim of this review is to summarize the clinical conditions that may be responsible for stunned myocardium.     

A case of spontaneous multivessel coronary artery dissection presenting with acute myocardial infarction and ventricular tachycardia

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia. Multivessel SCAD is much rarer than single vessel involvement and acute coronary syndrome remains the most common clinical presentation of a patient with SCAD. It predominantly occurs in association with atherosclerosis or in the absence of atherosclerosis. We, hereby, present a case of spontaneous multivessel coronary artery dissection in a 35‐year‐old male patient presenting with chest pain and ventricular tachycardia following emotional stress and discuss the etiology and treatment options. © 2011 Wiley‐Liss, Inc.     

A case of takotsubo cardiomyopathy complicated by ventricular septal perforation

The patient was a 73-year-old female who developed chest pain and dyspnea 16 days after her husband passed away. ST segment elevation was detected on V(2-5) by electrocardiography and emergency coronary arteriography was done for suspected acute myocardial infarction. No coronary arterial stenosis was present and ventricular septal perforation and takotsubo cardiomyopathy were diagnosed by left ventriculography. The perforation was closed and the patient was discharged 23 days after surgery. This patient had a very rare case of takotsubo cardiomyopathy, which was complicated by ventricular septal perforation and was saved by surgical treatment. (Circ J 2008; 72: 1540 - 1543).     

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.     

Spontaneous coronary artery dissection: a neglected cause of acute myocardial ischaemia and sudden death.

Spontaneous coronary artery dissection is a rare cause of acute myocardial ischaemia. Eight consecutive fatal cases which occurred in women aged 34-54 years (mean 43) are described. The dissection involved the left anterior descending coronary artery in four, the left main trunk in two, the right coronary artery in one, and both left anterior descending and circumflex arteries in one. The clinical presentation was sudden death in six cases, and acute myocardial infarction in two. Diagnosis was made at necropsy in every case but one, in which coronary dissection was diagnosed during life by selective coronary angiography. The only ascertained risk factor was hypertension in one patient; none of the women was in the puerperium, and Marfan syndrome was excluded in all. Histology showed a haematoma between the coronary tunica media and adventitia, that flattened and occluded the lumen; a coronary intimal tear was detected in only two cases. Unusual histological findings were cystic medial necrosis in one case, eosinophilic inflammatory infiltrates in four, and angiomatosis of the tunica adventitia in one. Patients dying of spontaneous coronary dissection are usually middle aged women, with no coronary atherosclerosis and apparently no risk factors. Spontaneous coronary artery dissection is unpredictable, and sudden death is the usual mode of clinical presentation. Prompt diagnosis and life saving treatment is far from being achieved.     

Rare Giant T-Wave Inversions Associated With Myocardial Stunning: Report of 2 Cases

Prominent T-wave inversions are well recognized electrocardiographic signs that can occur in acute myocardial infarction (AMI). However, the giant negative T waves may be associated with myocardial stunning without AMI.This case report describes 2 patients without AMI who developed rare giant T-wave inversions measuring up to 35 mm in depth and QT prolongation after admission to hospital. While 1 patient presented with acute pulmonary edema, the other patient presented with severe chest pain at rest and transient ST elevation.The giant T-wave inversion with QT prolongation may be caused by myocardial stunning due to the triple vessel diseases and elevated wall stress, high-end diastolic pressure and decreased coronary arterial flow during pulmonary edema in the first patient. The giant T-wave inversion with QT prolongation in the second patient may be caused by myocardial stunning due to the left anterior descending artery spasm (transient ST elevation) leading to transient total occlusion of left anterior descending artery. Percutaneous coronary intervention was successfully undergone for both patients. The patients remained well.The electrophysiologic mechanism responsible for giant T-wave inversion with QT prolongation is presently unknown. The two cases demonstrate that the rare giant negative T waves may be associated with myocardial stunning without AMI.     

Spontaneous Coronary Artery Dissection with Cardiac Tamponade

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. Clinical presentation ranges from chest pain alone to ST-segment-elevation myocardial infarction, ventricular fibrillation, and sudden death. The treatment of patients with spontaneous coronary artery dissection is challenging because the disease pathophysiology is unclear, optimal treatment is unknown, and short- and long-term prognostic data are minimal.We report the case of a 70-year-old woman who presented with an acute ST-segment-elevation myocardial infarction secondary to a spontaneous dissection of the left anterior descending coronary artery. She was treated conservatively. Cardiac tamponade developed 16 hours after presentation. Repeat coronary angiography revealed extension of the dissection. Medical therapy was continued after the hemopericardium was aspirated. The patient remained asymptomatic 3 years after hospital discharge. To our knowledge, this is the first reported case of spontaneous coronary artery dissection in association with cardiac tamponade that was treated conservatively and had a successful outcome.     

Simultaneous and spontaneous multivessel coronary artery dissection presenting as congestive heart failure

Spontaneous coronary artery dissection (SCAD) is a rare cause of myocardial ischemia. Multivessel SCAD is much rarer than single vessel involvement and acute coronary syndrome is the most frequent clinical presentation of a patient with SCAD. The patient in this report had SCAD in both the left anterior descending and right coronary arteries at the same time. However, the clinical manifestation was not acute coronary syndrome but rather congestive heart failure. Successful angioplasty and stent placement was performed and the symptoms of congestive heart failure were successfully resolved with medical treatment.     

Myocardial bridging with a coronary artery aneurysm and left ventricular stunning

The authors present a case demonstrating the unusual combination of myocardial bridging with a coronary artery aneurysm complicated by acute transient left ventricular dysfunction due to myocardial stunning. The pathophysiology and current insights into myocardial bridging, coronary aneurysms and myocardial stunning are briefly discussed. The literature reveals only one other reported case of coronary aneurysms associated with myocardial bridging. In addition, although there are several reports of angina and myocardial infarction complicating bridging, there is only 1 other report of myocardial stunning specifically.     

Acute reversible left ventricular dysfunction following general anesthesia.

Acute reversible left ventricular dysfunction due to myocardial stunning is a known phenomenon during acute myocardial infarction, coronary angiography, coronary angioplasty or after coronary artery bypass surgery. We report a rare case of acute reversible dysfunction of the myocardium as a complication of general anesthesia in a patient with normal coronary arteries. This is a potentially fatal complication unless recognized early and treated aggressively.     

Takotsubo Syndrome (Stress Cardiomyopathy): An Intriguing Clinical Condition in Search of Its Identity

Takotsubo syndrome is a relatively frequent clinical entity presenting typically as an acute coronary syndrome in the absence of obstructive coronary artery disease and characterized angiographically by transient left ventricular systolic dysfunction, sparing the basal segments of the left ventricle (“apical ballooning”). Takotsubo syndrome characteristically affects peri- or postmenopausal women, albeit recent series show that men also are at risk. Takotsubo syndrome is characteristically triggered by severe emotional or physical stress, which suggests a pathogenic role for increased sympathetic activity leading to myocardial perfusion abnormalities and ventricular dysfunction. The reasons why severe emotional and physical stress result in the development of takotsubo syndrome in certain individuals but not others is still a matter of speculation, but strongly suggests the existence of predisposing factors/mechanisms in certain subjects. The present article reviews the different factors that can play a role in the development of takotsubo syndrome in different patients. We propose that triggers (ie, emotional stressors, physical stressors, iatrogenic stressors, and neurologic triggers), pathogenic mechanisms (ie, increased catecholamine levels, coronary vasomotor abnormalities leading to myocardial ischemia), and predisposing factors (ie, cardiovascular risk factors, endothelial dysfunction, comorbidities) all interact in a complex fashion and possibly differently in different patients to cause takotsubo syndrome. Identifying these factors may help in preventing and managing the condition more effectively.     

Transient left midventricular dyskinesia: clinical features of a new variant

We report five consecutive patients with transient midventricular dyskinesia, a recently described variant of transient apical dyskinesia. It is a syndrome that shares a broad clinical, prognostic and, probably, pathogenetic resemblance to the latter. The patients, the majority of whom were experiencing an episode of emotional or physical stress, were all admitted to an emergency department with a clinical presentation compatible with acute myocardial infarction. Evidence of dyskinesia or akinesia in midventricular segments was seen on ventriculography. These ventricular abnormalities resolved completely over a short period of time. No coronary artery abnormality was evident in any patient. The existence of this variant shows that segments other than apical ventricular segments, which are affected in takotsubo syndrome, can also undergo reversible change. The occurrence of new variants raises further questions about the relationship between the nervous system, catecholamines and reversible myocardial lesions.