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.     

Three-dimensional echocardiographic assessment of left ventricular function in takotsubo cardiomyopathy

We evaluated left ventricular (LV) function by three-dimensional echocardiography (3DE) in a patient with takotsubo cardiomyopathy (TC). An 82-year-old man was admitted to our hospital with a suspicion of acute myocardial infarction but was diagnosed as TC by coronary angiography and left ventriculography (LVG). Three-dimensional echocardiography showed circular asynergy from the midventricle to the apex associated with hyperkinesis of the base and volumetric data very close to those obtained by LVG. Thus, 3DE is a useful tool in evaluating regional wall motion abnormalities and LV volume in patients with TC.     

Stress cardiomyopathy in a Caucasian man

Stress cardiomyopathy is increasingly being described as a form of reversible left ventricular systolic dysfunction, with a characteristic shape on left ventriculography. The acute clinical, electrocardiographic and laboratory abnormalities are reminiscent of acute coronary syndrome, with nonobstructive coronary arteries on angiography. Wall motion abnormalities typical of this disease exhibit apical akinesis with compensatory basal hyperkinesis, resulting in the characteristic systolic apical ballooning. Stress cardiomyopathy is much more common in women than men, especially postmenopausal women, and it is typically triggered by intense medical, emotional or physical stress. The pathogenesis of the disease is not well understood, with current evidence favouring catecholamine myocardial injury. Until prospective distinction can be made between stress car-diomyopathy and acute coronary syndrome, the diagnosis should be that of exclusion. In addition to long-term beta-blockers, angiotensin-converting enzyme inhibitors and diuretics as needed, treatment is generally supportive, with recovery of baseline left ventricular function within a few weeks to a month.     

Reversible ventricular dysfunction takotsubo cardiomyopathy

BACKGROUND: Recently, many cardiologists have recognized the existence of a rapidly reversible form of heart failure of unknown origin characterized by a takotsubo-shaped, dyskinetic left ventricle on left ventriculography. AIM: To determine the detailed clinical features of takotsubo cardiomyopathy. METHODS: Thirteen elderly patients (11 women and 2 men with a mean age of 75.3 years) who had normal coronary arteries and takotsubo-like left ventricular dysfunction were prospectively enrolled in this study. RESULTS: Cardiac enzymes did not increase significantly, but the mean plasma norepinephrine level was very high on admission (0.98 microg/l). Coronary angiography revealed normal coronary arteries in all patients, but left ventriculography showed apical akinesis combined with basal hyperkinesis, i.e., a takotsubo (Japanese octopus fishing pot)-shaped ventricle. Left ventricular wall motion normalized within a mean of 16.9 hospital days in 12 patients, but 1 patient died of acute renal failure on hospital day 7. Cardiac events did not recur during a follow-up period of 0.5 to 5 years. CONCLUSION: Takotsubo cardiomyopathy seems to be a new type of acute heart failure, which generally has a good prognosis and does not recur. Myocardial damage by catecholamine overload, adrenoceptor hypersensitivity, and changes of catecholamine dynamics due to stress may cause this condition.     

Rupture of free wall of left ventricle in a patient with takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) belongs to rare heart disease with symptoms imitating acute coronary syndrome with ST segment elevation. Usually, it occurs predominantly in postmenopausal women. In most cases, the disease has an uncomplicated course, but some patients may develop severe complications (e.g. cardiogenic shock, severe heart failure, malignant arrhythmia, thromboembolism or myocardial wall rupture). This case report describes an 82-year-old man with TTC complicated rupture of the left ventricular free wall and interventricular septum. This rare complication often leads to sudden death. Due to the unknown etiopathogenesis, the treatment is symptomatic. Pharmacologic therapy is still a matter of debate and further research.     

Quick resolution of takotsubo cardiomyopathy: a brief review

Takotsubo cardiomyopathy is characterized by transient mid- and apical ventricular dysfunction disguising as acute coronary syndrome but carries a good prognosis. Though spontaneous resolution is common, clinical manifestations may last weeks. We describe a case of quick resolution of left ventricular dysfunction and clinical symptom. We also reviewed the literature regarding timing and possible sources of variation in improvement in ventricular function.     

Torsade de pointes associated with bradycardia and takotsubo cardiomyopathy

Two cases of torsade de pointes associated with bradycardia and takotsubo cardiomyopathy are reported. In both cases, atrioventricular block preceded the occurrence of takotsubo cardiomyopathy. Bradycardia-induced QT interval prolongation seemed to be amplified by the occurrence of takotsubo cardiomyopathy, resulting in torsade de pointes. Temporary ventricular pacing at a high rate decreased the QT interval and prevented the recurrence of torsade de pointes. Because atrioventricular block recurred or persisted even after the resolution of takotsubo cardiomyopathy, the patients received permanent pacemakers.     

Meta-analysis of incidence and outcomes of life-threatening arrhythmias in takotsubo cardiomyopathy

BackgroundTakotsubo cardiomyopathy (TC) or stress-induced cardiomyopathy is a transient heart condition that clinically resembles an acute coronary syndrome. This study aims to assess the incidence of life-threatening arrhythmias in patients with Takotsubo cardiomyopathy and evaluate the outcomes of patients with life-threatening arrhythmias (LTAs) in Takotsubo cardiomyopathy compared with those without LTA.MethodsWe comprehensively searched the PubMed, Google Scholar, and Embase databases from inception to February 2021. The primary aim of the study was to determine the incidence of LTAs in TC patients. Other outcomes of interest were the odds of in-hospital, long-term mortality, and cardiogenic shock (CS) in TC patients with LTAs versus those without LTAs. For all statistical analyses, ReviewManager and MedCalc were used.ResultsEighteen studies were included in this study involving 55,557 participants (2,185 with LTAs and 53,372 without LTAs). The pooled incidence of LTAs in the patients of TC was found to be 6.29% (CI: 4.70–8.08%; I2 = 94.67%). There was a statistically significant increased risk of in-hospital mortality (OR = 4.74; CI: 2.24–10.04; I2 = 77%, p < 0.0001) and cardiogenic shock (OR = 5.60; CI: 3.51–8.95; I2 = 0%, p < 0.00001) in the LTA group versus the non-LTA group. LTA was not associated with long-term mortality (OR = 2.23; CI: 0.94–5.28; I2 = 53%, p = 0.07).ConclusionThe pooled incidence of life-threatening arrhythmias in the patients of TC was found to be 6.29%. In the group of TC patients with LTAs, the odds of in-hospital mortality and CS, was higher than in the TC patients without LTAs.     

Clinical and echocardiographic analysis of patients suffering from recurrent takotsubo cardiomyopathy

Background Recurrence of takotsubo cardiomyopathy (TTC) is a well-known complication. However, current literature lists only a few isolated cases. We aimed to determine the incidence and clinical significance of recurrent TTC. Methods & Results Our institutional database constituted a collective of 114 patients diagnosed with TTC since 2003. Close follow-up of these patients revealed a recurrence of TTC in seven of these (6.1%). The time interval between the index event and its recurrence varied between six months and six years. Arterial hypertension was more revealed in the recurrence group of TTC compared to non-recurrence group, (P = 0.02). Chronic obstructive pulmonary disease and/or asthma was more diagnosed in the recurrence group, (P = 0.04). Clinical events like right ventricular involvement, TTC related complications such as life-threatening arrhythmias, pulmonary congestion and in hospital death were observed more frequently in the recurrent episode. Over a mean follow-up of one year the mortality rate was similar in both groups. Conclusions Recurrence of TTC with?in six years after index event is not an uncommon phenomenon. In the event of right ventricular involvement in the relapse phase, it might be associated with a higher complication rate. TTC recurrence should be the first differential diagnosis in patients with a past history of TTC.     

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.     

Consequences of misdiagnosis and mismanagement of takotsubo cardiomyopathy

We report a patient who presented with takotsubo cardiomyopathy but was misdiagnosed as an anterior wall ST elevation myocardial infarction (AWMI). We illustrate how misdiagnosis led to mismanagement by initiating intravenous inotropic agents that led to further hemodynamic compromise. Subsequent withdrawal of the inotropic agents and simultaneous administration of oral metoprolol therapy led to hemodynamic and clinical improvement re-affirming the diagnosis of takotsubo cardiomyopathy.     

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.