Acute Pericarditis as an Effect or Cause of Takotsubo Cardiomyopathy

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Case presentation: A 60-year-old woman presented to the emergency department 2 hours after the onset of severe retrosternal chest pain that started soon after she was told that her son had died in a car accident. A 12-lead ECG demonstrated ST-elevation in the precordial leads (Figure 1), and the plasma troponin T level was elevated at 0.07 ng/mL. A diagnosis of acute ST-elevation myocardial infarction was made, and the patient was admitted for emergency coronary angiography, which revealed normal coronary arteries. The left ventriculogram showed severe systolic dysfunction involving the mid and apical segments (Data Supplement Movie I). Figure 1. Twelve-lead ECG demonstrating ST-segment elevation in precordial leads. Physicians have long been aware of the possible association between stress and cardiovascular events. Awareness has increased of a distinct cardiac syndrome that was originally described in the Japanese population and was called Takotsubo cardiomyopathy, named after the octopus-trapping pot with a round bottom and narrow neck that resembles the left ventriculogram during systole in these patients.1,2 Other names used to describe the condition include apical ballooning syndrome (ABS), broken heart syndrome, and stress or ampulla cardiomyopathy. The precise incidence of ABS is unknown, but it may account for 1% to 2% of patients who present with an acute myocardial infarction.3 The majority of patients have a clinical presentation that is indistinguishable from an acute coronary syndrome. Most present with chest pain at rest, although some patients have dyspnea alone as their initial presenting symptom. Rarely, patients present with syncope or an out-of-hospital cardiac arrest.4 ABS appears to occur almost exclusively in postmenopausal women; however, a few cases have been reported in younger women and males.4 The patients are usually hemodynamically stable, but clinical findings of mild-to-moderate congestive heart failure …

The Case for Takotsubo Cardiomyopathy (Syndrome) as a Variant of Acute Myocardial Infarction

Stress Cardiomyopathy: The Midventricular Variant

57-Year-Old Man With Atypical Chest Pain

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

A 65-year-old female patient admitted to the emergency department was diagnosed with acute high lateral myocardial infarction, but later Takotsubo cardiomyopathy (TC) was discovered. She had squeezing chest pain that started shortly after an emotional stress. The electrocardiogram revealed a loss of R wave voltage in leads V1 to V4 and an ST-segment elevation in I and aVL. After an urgent coronary angiography and ventriculography, TC was considered, and supportive anti-ischemic treatment was started. The severe left ventricular systolic dysfunction improved and normalized during the follow-up. She was discharged without any complications. TC is a new entity of acute cardiac events, and patients usually recover completely without sequelae with proper diagnosis and management. An exact diagnosis may also prevent an inappropriate application in the setting of recurrences.

Acute Pericarditis: Appendicitis of the Heart?

Acute pericarditis: appendicitis of the heart?

Over the past years, echocardiography has been shown to play a pivotal role in the accurate evaluation of left ventricular function particularly in patients with ischemic heart disease and various manifestations of cardiomyopathy [1]. The ability to rapidly perform bedside echocardiography with Echo-Doppler imaging places this modality in the heart of clinical research to understand cardiac function and to quantify various associated abnormalities. Echocardiography has found a major niche in visualizing left ventricular function in diverse manifestions of cardiomyopathies. For instance, widespread use of echocardiography has contributed to more frequent recognition of takotsubo stress cardiomyopathy [1–3]. Takotsubo cardiomyopathy has recently been recognized in patients with typical signs of acute myocardial infarction mostly due to emotional stress [4]. The disease may mimic an acute coronary syndrome and the acute course can be complicated by heart failure, arrhythmias, dynamic left ventricular outflow tract obstruction, hypotension and death [5]. In these patients the coronary arteries appear normal but they show reversible wall motion abnormalities [6, 7]. In the current issue of the International Journal of Cardiovascular Imaging, Chockaligam et al. [8] nicely reviewed the clinical presentation of takotsubo stress cardiomyopathy and proposed a unified diagnostic algorithm for cardiologists acutely managing this cardiac emergency. Also the pivotal role of echocardiography was emphasized and the nuances of this peculiar acute cardiomyopathy from an echocardiographers’ perspective were put forward. Accurate evaluation by echocardiography may assist in refining the diagnosis of takotsubo cardiomyopathy and to unravel its pathophysiological mechanism. The diagnosis of stress cardiomyopathy appears appropriate when angiography reveals no culprit lesions and left ventricular apical ballooning is typically seen. For example, at first sight, stress cardiomyopathy appears like an evolving left anterior descending infarction with akinesia of the apex, apical anterior wall and septum. At a closer view of the two-dimensional images from the apical four- and two chamber views, typical stress cardiomyopathy manifests as symmetrical regional wall motion abnormalities extending equally into the apical inferior and lateral walls. However, the definitive diagnosis of stress cardiomyopathy is confirmed when echocardiography repeated after few days to weeks shows complete normalization of regional wall motion abnormalities and left ventricular ejection fraction. Interestingly, the authors also revealed that about 25% of patients with stress cardiomyopathy very likely manifest left ventricular outflow tract obstruction. Loading conditions may significantly alter the severity of left ventricular outflow tract obstruction which may be a transient phenomenon. Left ventricular outflow tract obstruction can be precipitated when a small left ventricle develops hypercontractility, especially in the basal segments. This may lead to acute systolic subendocardial wall stress. This left ventricular strain consisting of both the systolic blood pressure and increased wall stress may result in myocardial stunning and cause the acute ballooning syndrome. Also advanced echocardiographic techniques such as tissue Doppler imaging, regional strain imaging and time-volume curves from three-dimensional echo image modeling may offer visually better demonstration of the regional wall motion abnormalities of stress cardiomyopathy with higher diagnostic sensitivity. Lastly, transesophageal echocardiography may provide anatomic details that may direct repair or replacement of the mitral apparatus when significant MR persists after stress cardiomyopathy and left ventricular outflow tract obstruction have resolved. As also mentioned by the authors, magnetic resonance imaging (MRI) has become an important imaging modality in patients with a broad spectrum of cardiomyopathies [2, 9–56], in particular in patients with takotsubo cardiomyopathy [57–61]. In a recent study, the value of MRI has been shown by using its capability of myocardial tissue characterization [57]. At coronary angiography all patients showed normal coronary arteries; four patients had apical ballooning and four patients had midwall- or basal ballooning. MRI was performed at hospital admission and the images were analyzed with commercially available software (QMASS MR Version 6.2.1, Medis, Leiden, the Netherlands). A T2-weighted imaging technique was used and it was found that T2-signal intensity was significantly higher in the dysfunctional segments, potentially indicating the presence of myocardial edema in the affected areas that showed ballooning. In the five patients who had a 2–3 week follow-up MRI scan, there was normalization of the wall motion abnormalities associated with a significant reduction in T2 signal intensity. As a result, it might be of great interest to know the pathophysiological condition of the affected myocardial tissue in the setting of the acute myocardial infarction in patients with stress cardiomyopathy. Both echocardiography- and MRI-derived parameters may therefore be of great significance in the follow-up of these patients as they may show spontaneous recovery of the cardiac abnormalities. To summarize, both echocardiography and MRI have their own specific value in the evaluation of patients with takotsubo cardiomyopathy. Of course, echocardiography, by virtue of its versatility and accessibility, wlll remain the first imaging modality of choice in routine clinical practice.

Assessment of Left Ventricular Dysfunction in Tako-Tsubo Cardiomyopathy

Use of Cardiac Magnetic Resonance Imaging to Distinguish Between Acute Myocarditis and Takotsubo Cardiomyopathy

Chest pain and reversible midventricular ballooning in a woman after witnessing sudden cardiac death: A possible variant of takotsubo cardiomyopathy

Patient: Male, 34Final Diagnosis: Takotsubo myocardiopathy and hyperthyroidismSymptoms: Chest pain • dyspneaMedication: —Clinical Procedure: —Specialty: CardiologyObjective:Rare co-existance of disease or pathologyBackground:Takotsubo cardiomyopathy (TM), also called stress myocardiopathy or transient left ventricular apical ballooning syndrome, is characterized by acute left ventricular dysfunction with reversible wall motion abnormalities. TM resembles acute coronary syndrome (ACS) in the absence of coronary artery disease (CAD).In several reports, TM has been described in association with hyperthyroidism, suggesting the potential role of thyrotoxicosis in the pathophysiology.Case Report:We present the case of a 34-year-old man with TM associated with hyperthyroidism caused by Graves’ disease. In this case, TM was also preceded by an emotional trigger.The diagnosis of TM was based on clinical manifestations, electrocardiographic and echocardiographic abnormalities, and the absence of coronary artery disease (CAD) in the angiography. A diagnosis of hyperthyroidism was made based on hormonal and antibody measurements. The patient had a favorable outcome, and the cardiac and thyroid disorders resolved.Conclusions:Our case illustrates that thyroid disease, mainly hyperthyroidism, should be considered in patients with TM with or without previous emotional triggers. As in our patient, the outcome in TM is usually favorable, with reversibility of cardiac abnormalities.

78-Year-Old Woman With Intermittent Chest Pain and Palpitations