Delayed-contrast enhancement cardioresonance in transient left ventricular apical ballooning

Transient left ventricular apical ballooning (TAB) is a condition that mimics acute coronary syndrome typically without coronary angiographic stenosis. Patients present with typical chest pain, ECG changes suggesting ischemia, and a slight elevation of myocardial injury markers such as Creatine kinase and Troponines. Ballooning during ventricular systole of the cardiac apex is a characteristic feature of this entity. It is transient and it usually resolves after a few days together with normalization of ECG changes. Initially, apical dyskinesis can be diagnosed by any cardiac imaging technique that allows myocardial wall motion assessment. Recent advances in cardiovascular magnetic resonance imaging (CMR) have made this technique to become the gold-standard method to assess myocardial infarction. CMR provides an excellent and reproducible assessment of segmental wall motion abnormalities and, more importantly, it allows an accurate depiction of myocardial necrotic area by means of delayed contrast-enhancement method. Therefore, it may be particularly useful in the assessment of TAB by demonstrating segmental dysfunction in the absence of myocardial irreversible damage. We report three cases of TAB in which contrast- enhanced CMR emerged as an excellent diagnostic tool.     

A case of transient left ventricular apical ballooning syndrome in a child: clinical features and imaging findings

Transient left ventricular apical ballooning syndrome (TLVABS) is an acute cardiac disease that is characterized by transient left ventricular systolic dysfunction involving the apical region. The symptoms and electrocardiographic changes of TLVABS mimic those observed in acute myocardial infarction while obstructive coronary arterial lesions are not seen in patients with TLVABS. TLVABS usually occurs in elderly women after physical or emotional stress. However, it is very rare in children and so it not well known to pediatricians. Accordingly, TLVABS in children can be misdiagnosed as myocarditis or cardiomyopathy. We report here on a case of child who showed the typical findings of TLVABS in association with pericarditis. He presented with dyspnea and pericardial effusion, which required pericardiocentesis. After pericardiocentesis, he showed the typical echocardiographic and electrocardiographic findings of TLVABS. The MRI findings at 14 days after the initial symptoms showed normal coronary arteries and normal left ventricular function without any wall motion abnormalities. In addition, no delayed hyper enhancement was found on delayed-enhanced (DE)-MRI. We also reviewed the other reported cases of TLVABS in patients who were under the age of 40.     

左室心尖球囊综合征1例

患者,女,82岁,因"玩麻将出现胸闷、泌汗1小时"入院.于急诊室突发心室颤动电复律后收入CCU病房,复律后心电图示:ST段V2～V6、I、aVL抬高0.1～0.7 mV频发室早及肢导低电压.     

Tei指数评价左心室心尖球形综合征患者左心室功能

目的 探讨定量组织速度成像(QTVI)技术测量Tei指数评价左心室心尖球形综合征(LVABS)患者左心室整体功能的价值。 方法 收集7例LVABS患者(LVABS组)及20名健康体检者(对照组),于入院时、4周末、8周末行超声心动图检查,应用QTVI技术测算左心室Tei指数及舒张早期峰值速度/舒张晚期峰值速度(Ea/Aa),以双平面Simpson法测算左心室射血分数(EF)。 结果 LVABS组患者入院时、4周末、8周末左心室Tei指数逐渐降低,平均Tei指数(Tei_M)与对照组的差异均具有统计学意义(P均<0.05);LVABS组4周末、8周末时EF逐渐升高,与入院时相比较差异均具有统计学意义(P均<0.05);Tei_M与EF呈负相关(入院时、4周末、8周末:r=-0.913、-0.932、-0.946; P均<0.05);LVABS组4周末、8周末时Ea/Aa逐渐升高,与入院时相比较差异均具有统计学意义(P均<0.05);Tei_M与Ea/Aa呈负相关(入院时、4周末、8周末:r=-0.779、-0.821、-0.853;P均<0.05)。 结论 QTVI技术测量Tei指数能有效地综合评价LVABS患者左心室整体功能,其中前壁及前侧壁测值尤为敏感。     

Transient left ventricular dysfunction with apical ballooning (tako–tsubo cardiomyopathy) in Germany

Summary Aims A peculiar type of an acute coronary syndrome is characterised by acute onset of chest pain, STsegment changes, elevated troponin I levels and a transient balloon–like apical left ventricular dysfunction, but without significant coronary artery disease. We sought to assess this syndrome in German patients. Methods and results A total of 22 females and 1 male with acute transient left ventricular dysfunction were identified during an interval of 2 years and were investigated clinically and angiographically. All patients presented without obstructive coronary artery disease. In 16 patients (70%) ST–segment elevations were observed mimicking acute myocardial infarction, whereas the remaining patients (30%) revealed only negative T waves. Deep negative Twaves were characteristically seen during the course of recovery in all patients. Elevated troponin I levels > 2.0 μg/l (upper level of normal) were measured in all patients (mean 18 ± 26.5 μg/l, range from 2.2–135.7 μg/l). Creatine kinase rose up to a mean of 282 ± 236 IU/l (upper level of normal 180 U/l). Emotional or physical stress situations associated with the onset of the symptoms were observed in 16 patients (70%). Other suspected trigger factors were gastrointestinal infection and in one case a surgical intervention. In four patients a trigger factor could not be identified. Left ventriculography showed an ejection fraction of 53 ± 15%. After an interval of 7 ± 2 days after the first angiogram, ejection fraction had increased from 48 ± 11% to 64 ± 11% in eight controlled patients by repeated ventriculography. Coronary spasm with a lumen reduction > 75% could be provoked using acetylcholine in 10 of 17 tested patients (59%) with reproduction of the symptoms. Within 14 days the LV dysfunction returned to normal in all patients. The ECG abnormalities disappeared completely as early as 3 months (74%) and were not seen in any patient after 6 months. Conclusion Tako–tsubo cardiomyopathy is not exclusively a Japanese or Northern American phenomenon. Despite increased patient reports the exact underlying cause and pathophysiology of this syndrome remain unclear. However, despite the initial dramatic presentation of this disease the prognosis is good.     

Left ventricular apical ballooning

Transient left ventricular apical ballooning is an acute cardiac syndrome characterised by an abrupt onset of chest pain and is usually associated with anterior electrocardiographic changes. The observed apical ballooning of the left ventricle is usually reversible and develops in the absence of significant atherosclerotic coronary artery disease. Here we present (to our knowledge) the first case of this syndrome in a negroid patient.     

Tako-tsubo-like left ventricular dysfunction with ST-segment elevation after central spinal cord injury: a case report

The etiology of a novel cardiac syndrome called "tako-tsubo" cardiomyopathy, otherwise known as "acute onset and reversible left ventricular apical wall motion abnormality (ballooning)," is very similar to that of acute myocardial infarction; however, it may also be associated with emotional or physical stress. We report a case of tako-tsubo-like left ventricular dysfunction with ST-segment elevation after trauma. A 69-year-old man was transferred to our hospital after a fall in which he injured his back. He was diagnosed with a central spinal cord injury and was admitted to our Intensive Care Unit. He complained of a sudden chest pain 12 h after the injury. ST-segment elevation was observed on the electrocardiographic monitor, and subsequent 12-lead electrocardiogram demonstrated ST-segment elevation in leads V(2) through V(5). We considered acute myocardial infarction or cardiac contusion to be the cause of this event; therefore, an emergency coronary angiography was performed. However, the angiography revealed no significant coronary artery stenosis. Furthermore, left ventriculography demonstrated severe hypokinesis of the left ventricular apical region, consistent with tako-tsubo-like left ventricular dysfunction. The patient's cardiac function improved gradually, and he was discharged from our hospital on the 18(th) day after admission. Physicians should recognize the syndrome of tako-tsubo-like left ventricular dysfunction, which may result from traumatic stress or chest injury.     

Recurrent tako–tsubo–like left ventricular dysfunction (apical ballooning) in a patient with pheochromocytoma—a case report

Summary Primarily described in Japan, tako–tsubo–like left ventricular dysfunction is a phenomenon characterized by transient apical ballooning in the absence of significant coronary artery disease. The clinical presentation includes symptoms like chest pain, dyspnea, syncope, electrocardiographic changes and elevated myocardial markers, all compatible with the diagnosis of an acute coronary syndrome. The underlying mechanism is supposed to be a catecholamine excess caused by various triggers. We describe a patient with a recurrent tako–tsubo phenomenon, who at work–up proved to have a pheochromocytoma as the most likely underlying disease.     

Cardiovascular magnetic resonance T2 signal abnormalities in left ventricular ballooning syndrome

Left ventricular ballooning syndrome (LVBS), also known as Takotsubo cardiomyopathy, is characterized by regional left ventricular dysfunction associated with severe psychological stress. T2 weighted cardiac magnetic resonance (CMR) can identify myocardial edema due to ischemia or other insults. A standard clinical CMR scan with double inversion recovery fast spin echo T2 weighted sequences was performed on consecutive patients with LVBS. T2 signal was compared in myocardial segments with normal and impaired function based on systolic wall thickening (SWT). Eight LVBS patients were identified, all female, with a median age of 61 years and median left ventricular ejection fraction of 52%. Four patients had apical ballooning and four had mid-wall or basal ballooning. In severely dysfunctional segments (those with SWT < 25%), the median percentage of high T2 signal was 85 compared with 35 in those with SWT > 25% (P < 0.001). When the segments were categorized into tertiles based on SWT, the percentage of high T2 signal was greatest in segments with the worst function (68% vs. 43% vs. 31%, P = 0.005). In the five patients who returned for follow up, there was a significant reduction in high T2 signal compared with baseline in those segments that were initially severely dysfunctional (85% vs. 35%, P < 0.001). In conclusion, we describe elevated T2 signal consistent with myocardial edema in patients with LVBS. The T2 signal is highest in myocardium with the most impaired function and resolves over time.     

Angiographic long-term follow-up of primary apical ballooning of the left ventricle

Acute and reversible left ventricular apical wall motion abnormalities presenting with chest pain, electrocardiographic (EKG) changes and cardiac markers release, in the absence of coronary artery stenosis, have already been identified as a possible distinct clinical entity: the so-called Tako-Tsubo syndrome. A 65-year-old man with history of hypertension, hypercholesterolemia and smoking, was admitted at the emergency room of a secondary referral institution with a severe and prolonged (45 min) chest pain, irradiated to the left arm, associated with neurovegetative syndrome. The clinical presentation suggested an acute myocardial infarction (AMI). Interestingly no coronary artery stenoses or vasospasm reaction to administration of acetylcholine could be detected. A slow flow phenomenon was present. The left ventricle angiography confirmed a mild depression of left ventricle systolic function (EF 45%), with akinesia of antero-lateral wall and the typical apical ballooning-like profile. At 3-month follow-up, the patient continued to be asymptomatic and the echocardiogram showed a progressive normalization of left ventricle segmental motion and ejection fraction with a complete restoration only after 6 months. At 1 year the coronary angiography confirmed the absence of coronary stenosis, with complete regression of the ventricular apical ballooning at left ventricle catheterization. At two-year follow-up the patient is still asymptomatic. A slow resolution of the syndrome should be included in the diagnostic criteria for apical ballooning.     

可逆性左室功能紊乱

日本学者首次提出了Tako-tsubo 综合征(心尖球样综合征),自此之后,此种综合征日益受到人们的广泛重视.此病常发生于情感打击或应激情况下的老年女性,临床特点主要包括急性缺血样胸痛,心电图表现出ST段改变、T波倒置,心肌酶等标志物水平轻度升高,是一过性的心尖部及心室中部局部室壁运动不良,但冠脉造影结果未见明显异常,大多预后良好,需与急性冠脉综合征相鉴别.但其具体发生机制,目前尚未明确.Tako-tsubo综合征的研究已引起人们的广泛关注,本文就其主要表现及发生机制方面的研究进展进行综述.     

左室心尖部室壁瘤的鉴别诊断

左室心尖部室壁瘤大部分为心肌梗死后的并发症，超声心动图在室壁瘤的诊断中具有较高敏感性和特异性，但由于检查者对少见相关疾病认识不足而容易造成误诊，本文通过回顾分析室壁瘤超声图像与相关临床资料，鉴别出部分误诊为室壁瘤的少见病和正常变异，如：假性室壁瘤、左室憩室、肌间裂隙、应激性心肌病，详细总结上述少见病的基本特征，有助于帮助基层超声医师提高心尖部病变的诊断能力。