Apical Ballooning Syndrome Research Articles

Transient left ventricular and stomach apical ballooning syndromes: when the trigger is also a clinical emergency

A 59-year-old woman was referred to our emergency department because of epigastric pain and incoercible vomit. Electrocardiogram showed ST-segment elevation in anterior-lateral leads, but coronary angiogram revealed normal coronary tree and left ventricular angiography showed apical and midventricular akinesis with preserved basal systolic function: a diagnosis of apical ballooning syndrome was made. During the following days, the patient complained about persistent abdominal pain, and a nasogastric tube drained more than 1000 cc of dark fecaloid material. Urgent abdominal computed tomography scan showed a mural thrombus in the apex of the left ventricle and a huge diaphragmatic hernia through which more than one-half of the stomach was herniated and presented a sort of “apical stomach ballooning.” Gastropexy was done; surgical diagnosis was a type IV giant diaphragmatic hernia complicated by recent gastric volvulus caused by rotation along the longitudinal cardiopyloric axis. Type IV giant diaphragmatic hernia is relatively rare, representing only about 5% to 7% of all hernias. Gastric volvulus is a severe complication, with acute mortality reported to be as high as 30% to 50%. In our case, a severe life-threatening condition as gastric volvulus triggered an apical ballooning syndrome, a transient cardiomyopathy, usually induced by emotional stressors with a long-term good prognosis. Apical ballooning syndrome must be considered an epiphenomenon of other organic diseases that may have an important role in the prognosis of the patient not only in acute but also in chronic setting. Only early determination of the true cause of apical ballooning syndrome ensures a proper treatment.

Clinical Features of Takotsubo Cardiomyopathy - A Single-Center Experience

Takotsubo cardiomyopathy (TTC), also known as transient apical ballooning syndrome or stress-induced cardiomyopathy, is a distinctive reversible condition often affecting postmenopausal women after a stressful event. It is characterized by sudden temporary systolic dysfunction of the apical and/or mid-segments of the left ventricle. The underlying mechanisms have not yet been elucidated, but several hypotheses include catecholamine cardiotoxicity, microvascular dysfunction and coronary artery spasm. We conducted a retrospective descriptive study on patients with the discharge diagnosis of TTC from 2003 to 2012 at Danbury Hospital, Danbury, Conn., USA. A total of 78 patients met the Modified Mayo Criteria for the Diagnosis of TTC and were included in the study. Clinical characteristics at baseline, past surgical and medical history including psychiatric records were reviewed and recorded. The mean age was 70.5 ± 14 years, 87% (n = 68) were women, of which 11.7% (n = 8) were aged ≤55 years. Depression was present in 20.5% (n = 16) of the patients and anxiety in 30.8% (n = 24). Twenty-one patients (27.3%) reported a preceding emotional stressful event and 31 (40.3%) had a preceding physical stressor. Fifty patients (64.1%) presented with chest pain, 28 (35.9%) had ST-segment elevation upon admission and 5 (6.3%) died during their hospital stay. TTC is becoming an increasingly recognized condition and clinicians should include it in the differential diagnosis of patients presenting with a suspected acute coronary syndrome. It is frequent in postmenopausal women with preceding physical or emotional stress and overall prognosis is good among patients who survive the initial acute phase of heart failure.

Acute phase myocardial edema was related to recovery process of regional left ventricular wall motion abnormality in takotsubo cardiomyopathy

Background: Takotsubo cardiomyopathy (TC, stress cardiomyopathy, apical ballooning syndrome) is characterized by transient reversible systolic dysfunction of the apical and/or mid segments of the left ventricular (LV). However, the recovery process of LV systolic dysfunction is not known in detail. Methods: We retrospectively evaluated 40 consecutive patients (38 women, 2 men) who were diagnosed as TC in our hospital between June 2007 and October 2012. Main outcome was complete recovery of LV wall motion. Clinical characteristics of early recovery group (n=16; LV wall motion recovered completely within 7 days) and late recovery group (n=24; abnormal LV wall motion remained after 7 days) were compared. Then, we recorded cardiovascular magnetic resonance imaging (CMR) within three days after hospitalization in 27 of 40 patients to evaluate an acute phase histological change of the diseased myocardium. Results: A stressful trigger could be identified in 26 patients (mental: 10, physical: 16). Average LV ejection fraction (LVEF) evaluated by left ventriculography was 50%. There were no statistically significant differences about age, coronary risk factor, laboratory data, QTc in electrocardiogram, and LVEF between two groups. Regional myocardial edema (high intensity in T2-weighted images of CMR) could be identified in 5 of 9 patients (56%) in early recovery group and 18 of 18 patients (100%) in late recovery group (P<0.05). ![Figure][1] Figure 1. Regional myocardial edema on CMR Conclusions: Acute phase myocardial edema detected by CMR images may relate to recovery process of LV wall motion abnormality in TC patients. [1]: pending:yes

TakoTsubo Cardiomyopathy A Short Review

Takotsubo cardiomyopathy (TCM), otherwise cardiomyopathy,apical ballooning syndrome or broken heart syndrome is a reversible cardiomyopathy, predominantly occurs in post-menopausal women and commonly due to emotional or physical stress. Typically, patients present with chest pain and ST elevation or T wave inversion on their electrocardiogram mimicking acute coronary syndrome, but with normal or non-flow limiting coronary artery disease. Acute dyspnoea, hypotension and even cardiogenic shock may be the presenting feature of this condition. The wall motion abnormalities typically involve akinesia of the apex of the left ventricle with hyperkinesia of the base of the heart. Atypical forms of TCM have also recently been described. An urgent left ventriculogram or echocardiogram is the key investigation to identify this syndrome. Characteristically, there is only a limited release of cardiac enzymes disproportionate to the extent of regional wall motion abnormality. Transient right ventricular dysfunction may occur and is associated with more complications, longer hospitalisation and worse left ventricular systolic dysfunction. Recently, cardiac MRI has been increasingly used to diagnose this condition and to differentiate from acute coronary syndrome in those who have abnormal coronary arteries. Treatment is often supportive, however beta-blocker and angiotensin-converting enzyme inhibitor or angiotensin II receptor blocking agent are being used in routine clinical practice. The syndrome is usually spontaneously reversible and cardiovascular function returns to normal after a few weeks. This review article will elaborate on the pathophysiology, clinical features including the variant forms, latest diagnostic tools, management and prognosis of this condition.

Sequential transition of mid-basilar variant to apical form of Takotsubo syndrome

Takotsubo syndrome, also called apical ballooning syndrome, is a clinical entity characterized by transient hypokinesis, akinesis, or dyskinesis of the left ventricular mid and apical segments without flow limiting obstructive coronary lesions. There have been many reported morphologic variants of apical ballooning syndrome based upon distribution of segment involvement including traditional apical, midventricular, and basilar. We present a patient who demonstrated sequential transition of mid-basilar type to classical apical ballooning type.<Learning objective: Takotsubo syndrome mimics acute coronary syndrome and is accompanied by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis. Many morphological presentations can present, hence increased awareness may help practitioners identify and properly treat this condition. This is the first reported case of a sequential transition between variants.>

Diagnosis and treatment of apical ballooning syndrome complicated with asthma: a case report and literature review

Diagnosis and treatment of apical ballooning syndrome complicated with asthma: a case report and literature review

Quantitative evaluation of left ventricular systolic dyssynchrony in patients with left ventricular apical ballooning syndrome by real-time three-dimensional echocardiography

Objective To evaluate the left ventricular systolic dyssynchrony in patients with left ventricular apical ballooning syndrome (LVABS) quantitatively by real-time three-dimensional echocardiography(RT-3DE) and its correlation with left ventricular ejection fraction(LVEF).Methods 7patients with LVABS were enrolled in this study.The images of left ventricle in full volume mode were obtained by RT-3DE in the different time (just after admission,4 weeks and 8 weeks).Post-processing software of 4D LV Volume Tom-Tec was used for calculation of EF and 16-segmental time-volume curves was obtained.The time to the point with minimal systolic volume(Tmsv) of each segment was calculated and by which the following indexes of systolic dyssynchrony were derived:Tmsv16-SD/Dif,Tmsv-basalSD/Dif,Tmsv-mid-SD/Dif and Tmsv-apical-SD/Dif.The correlation between systolic dyssynchrony index (SDI) and LVEF was analysed.Results ① The Tmsv16-SD/Dif,Tmsv-basal-SD/Dif,Tmsv-mid-SD/Dif and Tmsv apical-SD/Dif of left ventricle in the patients of 4 weeks and 8 weeks were smaller than those of the patients just after admission.There were significant differences among them(all P ＜0.05).②The more SDI increased,the more LVEF decreased,and vice versa.SDI was negatively associated with LVEF in the different time of admission (just after admission:r =-0.758; 4 weeks:r =-0.831 ; 8 weeks:r =-0.889;all P ＜0.05).Conclusions Left ventricular systolic dyssynchrony of severe degree is observed in patients with LVABS just after admission.But the condition of dyssynchrony has been improved gradually after 4 weeks and 8 weeks.SDI is negatively correlated with LVEF. Key words: Echocardiography,real-time three-dimensional; Cardiomyopathies; Ventricular function,left; Left ventricular apical ballooning syndrome

Lost memories can break your heart: a case report of transient global amnesia followed by takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC), also called apical ballooning syndrome, is characterized by an acute, transient systolic dysfunction of the apical and mid segments of the left ventricle. Recently, there have been reports showing an association with neurologic disorders including myasthenic crisis [1], Guillain–Barre–Strohl syndrome [2], seizures [3] and ischemic stroke [4]. In this article, we present the case of a woman, who suffered from a second episode of transient global amnesia (TGA) followed by TC. A 62-year-old woman presented to our emergency room with typical symptoms of TGA, thereby asking repetitive questions regarding the situation and events over the last hours. Symptom onset had occurred during the visit to a public swimming pool. Apart from isolated global amnesia, the neurologic examination was normal; a CT-scan of the brain was unremarkable. An EEG was done and ruled out an epileptic cause of the syndrome. Extracranial and transcranial vascular ultrasound did not reveal any pathologic findings. The patient had a past medical history of hypothyroidism with need for oral substitution and a previous episode of TGA 2 years before. Four hours after the patient was admitted to our intermediate care unit, she developed acute chest pain and dyspnoea. The troponin I level was elevated at 4.64 ng/ml. Acute coronary syndrome was suspected and an emergency coronary angiography was performed, which did not show relevant coronary artery disease. Ventriculography revealed severe hypokinesis of mid and apical segments of the left ventricle with the characteristic shape of takotsubo cardiomyopathy (Figs. 1, 2; supplemental ultrasound video Movie—TakoTsubo.mpg). The patient was stable during the further course and showed full recovery from all amnestic deficits within 18 h. On follow-up echocardiography, a complete normalization of cardiac function with normal left ventricular diameter, no wall motion abnormalities and a normal ejection fraction were found. The patient was then discharged in a good state of health. Transient global amnesia was first described in 1956 by Guyotat and Courjon as an acute cognitive disorder with predominantly anterograde amnesia for up to 24 h [5]. Most episodes occur at the age of 50–80 years, do not show an association with vascular risk factors and are frequently precipitated by emotional stress, physical effort, water Electronic supplementary material The online version of this article (doi:10.1007/s00392-013-0590-1) contains supplementary material, which is available to authorized users.

Biventricular Tako‐Tsubo cardiomyopathy: Usefulness of 2D speckle tracking strain echocardiography

Tako-Tsubo cardiomyopathy is a transient left ventricular apical ballooning syndrome also known as stress-induced cardiomyopathy. This reversible cardiomyopathy without epicardial coronary artery disease mimics acute myocardial infarction. Right ventricular involvement, which has been infrequently reported, is present in about a quarter of cases of Tako-Tsubo cardiomyopathy and is associated with a more severe clinical outcome. We report the case of a 55-year-old postmenopausal woman with transient biventricular apical ballooning. She recently had acute exacerbation of multiple sclerosis. Regional and global function of both ventricles was estimated using two-dimensional speckle tracking strain echocardiography.

Letter to the editor: Gabus et al. Left ventricular apical ballooning syndrome with extensive myocardial late gadolinium enhancement: Tako-tsubo cardiomyopathy, perhaps not as benign as previously thought. Cardiovascular Medicine. 2012;15:325-8.

Letter to the editor: Gabus et al. Left ventricular apical ballooning syndrome with extensive myocardial late gadolinium enhancement: Tako-tsubo cardiomyopathy, perhaps not as benign as previously thought. Cardiovascular Medicine. 2012;15:325-8.

Sudden cardiac death: An increasingly recognized presentation of apical ballooning syndrome (Takotsubo cardiomyopathy)

We present an unfortunate case of a previously healthy woman who suffered an out-of-hospital cardiac arrest in the setting of severe emotional distress, likely due to apical ballooning syndrome. This case highlights the fact that although patients with apical ballooning syndrome typically do well following recovery from transient left ventricular dysfunction, they should be monitored closely in the acute setting due to the potential for life-threatening arrhythmias.

Triple occurrence of Takotsubo cardiomyopathy

A 51 year-old woman after a quarrel with her husband and with no previous cardiovascular history was admitted to hospital with a suspicion of anterior myocardial infarction (MI) in 2005. She was suffering from chest pain; ECG documented ST-segment elevation in the V1–V3 leads and a positive troponin I level (2.8 ng/dL) was documented. An echocardiogram revealed akinesia of apical and mid-wall segments of left ventricular (LV) anterior wall and intraventricular septum with an ejection fraction (EF) of 45% (Fig. 1A, B). An urgent coronary angiography demonstrated no coronary artery disease (CAD). We observed full recovery with no LV contraction abnormalities at one-month follow-up. The subsequent focal type of Takotsubo cardiomyopathy (TTC) was diagnosed. Three years later, she presented with an inverse-type of TTC after knee surgery due to chest pain, ST-segment abnormalities in ECG and an increased troponin level (5.3 ng/dL). An echocardiogram and ventriculography revealed akinesia of all basal and mid-wall LV segments with an EF of 38% (Fig. 1C, D). We observed again a full clinical recovery with no LV wall motion abnormalities. A third hospitalisation, following a panic attack, occurred in 2009. The patient was referred for invasive diagnostics due to chest discomfort, ST-segment depression in ECG and a troponin I level of 1.1 ng/dL. Echocardiography and coronarography results were similar to those from the second episode (Fig. 1E, F). Therefore, a third occurrence of TTC was subsequently recognised. The most recent echocardiography showed normal LV contraction with an EF of 68% and normal longitudinal peak systolic strain for all LV regions (Fig. 1G, H). TTC, first described in 1990, usually affects postmenopausal women and is proceeded by psychological or physical stress. TTC mimics acute MI due to angina chest pain, ST-segment elevation pattern in ECG and a positive troponin level. However, obstructive CAD is in the majority of cases excluded. TTC, which is sometimes also known as apical ballooning syndrome, is predominantly characterised by transient, reversible, regional systolic dysfunction involving the LV apex and mid-ventricle with hyperkinesis of the basal LV segments. Case reports from the last 2 decades have also shown different faces of TTC concerning atypical TTCs such as inverse TTC with basal wall motion abnormalities, mid-segment TTC with akinesia presentation of all LV mid-segment and hyperkinesias of the basal and apical regions of LV, and focal TTC with regional wall motion disturbances. We here present a unique case of three TTC episodes in one patient after different stress events.

What happened to a thrombus during apical ballooning syndrome: a case report

What happened to a thrombus during apical ballooning syndrome: a case report

Myocardial bridging, apical ballooning syndrome and myocardial stunning: Shall we connect the dots?

affects L-type voltage-gated calcium channels [10]. Alternatively, NAC co-administered with Diltiazem might yield a pro-oxidant effect. Accordingly, we observed that drug combination increased cardiomyocyte ROS production more actively than either drug alone. In summary, combined intraoperative use of Diltiazem and NAC increases myocardial damage during off-pump cardiac surgery and should be avoided. The mechanisms of interaction require further investigation but it is likely that increased oxidative stress be involved.

Ultra-fast Tako-Tsubo cardiomyopathy after local anesthesia for eye surgery: Are we missing the submerged bottom of the iceberg?

Tako-Tsubo cardiomyopathy (TTC), also known as stress induced cardiomyopathy or apical ballooning syndrome, is a fully reversible acute deterioration of left-ventricular (LV) function, which is mainly found in women after an episode of either emotional or physical stress [1]. The underlying mechanisms remain not completely known [2], although increased catecholamine levels were thought to be mainly responsible for TTC [3–5]. Systolic dysfunction usually completely recovers in a few weeks, although delayed recovery (>2months) has been reported in 5%of patients [6].

Left ventricular apical ballooning syndrome with extensive myocardial late gadolinium enhancement

Left ventricular apical ballooning syndrome with extensive myocardial late gadolinium enhancement

Hyper-acute precipitating mechanism of Tako-Tsubo cardiomyopathy: In the beginning was basal hyperkinesis?

Tako-Tsubo cardiomyopathy (TTC), also known as stress inducedcardiomyopathy or apical ballooning syndrome, was first describedby Dote in 1991 [1].Itisdefined as a fully reversible acutedeterioration of left-ventricular function, which is mainly found inwomen after an episode of emotional or physical stress (e.g. psycho-social stress, sepsis, surgery) [2]. The underlying mechanisms remainunclear, although increased catecholamine levels were thought asmain responsible [3,4]. Even less known are the mechanismsunderlying the hyper-acute phase of TTC, which precede apicalballooning and are usually missed because they occur during thepre-hospital phase of the disease. We describe in this case thehyper-acute phase of TTC observed during early in-hospital recur-rence of TTC.A 74-year-old woman, with amyotrophic lateral sclerosis (ALS),referred for pneumonia, after a stressful event during hospitalization,complained of chest pain, with evidence at electrocardiogram of STelevation, negative T-waves in anterior leads, intra-ventricular

Takotsubo cardiomyopathy in siblings

We report the case of apical ballooning syndrome (ABS) in a female sibling. A 64-year-old woman was admitted to our hospital with sudden-onset chest pain. Cardiac enzymes were mildly elevated and an electrocardiogram showed broad ST-T changes. Emergency coronary angiography revealed no culprit lesion and left ventriculography demonstrated focal akinesis of the apical wall, which was consistent with ABS. Myocardial functional sympathetic innervations assessed using [(123)I]metaiodobenzylguanidine was severely impaired in the apical region. Her clinical symptoms and cardiac dysfunction recovered spontaneously. Just 1 year prior to our patient's cardiac event, her elder sister had the same symptoms and was also diagnosed with ABS. Both sisters were postmenopausal. The familial case of ABS is exceedingly rare, but these cases suggest a possible genetic etiology.

Trauma induced left ventricular apical ballooning syndrome in a 15 year old: A rare case of Tako-tsubo cardiomyopathy

We present a case of a 15 year old girl who developed transient left ventricular apical ballooning syndrome, Tako-tsubo cardiomyopathy, after a significant motor vehicle accident. On post-trauma day three she developed heart failure with mid-to-apical left ventricular wall dysfunction with an EF of 10%–15%. The patient eventually regained full cardiac function by post-trauma day seven. Here we present the first case report of trauma induced left ventricular apical ballooning syndrome in pediatrics.

Women and Heart Failure: An Emerging Venus-Mars Concept

Some of the most profound sex differences in cardiovascular disease are evident in the syndrome of heart failure. Certain heart failure conditions have a unique predilection for women, such as heart failure with preserved ejection fraction and apical ballooning syndrome; or are exclusive to women, such as peripartum cardiomyopathy. Overall, there are notable differences between women and men in terms heart failure disease burden, risk factors, clinical presentation and prognosis. Yet, women remain under-represented in heart failure clinical trials. Important knowledge gaps exist in our understanding of the pathophysiologic basis for these sex differences and potential for effective sex-specific management strategies.