Apical Ballooning Research Articles

Point-of-care Ultrasound Used in the Diagnosis of Reverse Takotsubo Cardiomyopathy

Case Presentation: We present a case of a patient who presented to the Emergency Department with palpitations, nausea, vomiting and chest discomfort found to have a reduced Ejection Fraction and basal wall hypokinesis on Point of Care Ultrasound concerning for reverse Takotsubo cardiomyopathy. Discussion: Reverse Takotsubo cardiomyopathy is a rare variant of Takotsubo cardiomyopathy and involves basal ballooning instead of apical ballooning. Ultrasound findings concerning for reverse Takotsubo cardiomyopathy are basal wall hypokinesis or akinesis.

12262 Pheochromocytoma Masquerading As An Acute Myocardial Infarction And Takotsubo Cardiomyopathy In A Hispanic Woman: A Case Report

Abstract Disclosure: A. Hoskote: None. J. Seidenberg: None. V. Gupta: None. Pheochromocytoma is a rare neuroendocrine tumor (<1 per 100,000 person-years) that occurs sporadically or due to mutations. While most patients do not have the classic headache, sweating and tachycardia, about 50% have paroxysmal hypertension and 90% have headaches. We present a rare case of pheochromocytoma masquerading as myocardial infarction (MI) and cardiomyopathy. A 67-year-old Hispanic female with history of hypertension and uncontrolled Type 2 DM, presented to the ER for chest pain and diaphoresis. Home medications were metformin, sitagliptin, lisinopril, simvastatin and aspirin. EKG showed non-specific ST elevations in chest leads without STEMI, and labs revealed a dynamic troponin and hemoglobin A1C of 13.6%. CT angiography ruled out pulmonary embolism. A left heart catheterization and echocardiogram revealed non obstructive coronary artery disease (CAD), a left ventricular ejection fraction of 25%, apical ballooning and a laminar thrombus. She was diagnosed with acute myocardial infarction and Takotsubo cardiomyopathy and discharged on metoprolol and apixaban. During our evaluation 7 months later, we noted several ER and hospital admissions for symptomatic hypertensive emergency with a pattern of labile blood pressures and on review of initial CT scan, a sequentially growing left adrenal mass (3.9cm 29HU) was present. A careful history using Spanish interpretation revealed episodic headaches, diaphoresis and palpitations. Subsequently, on two separate occasions, plasma normetanephrine was 2006 pg/mL (ULN<148 pg/mL) and urine normetanephrine was 12516 mcg/g cr (ULN <524 mcg/g cr). Prazosin was prescribed with stabilization of hypertension. An adrenalectomy is now scheduled. Symptoms of pheochromocytoma and paraganglioma (PPGs) are caused by hypersecretion of one or combinations of catecholamines: norepinephrine, epinephrine and dopamine. In one study 27% were discovered due to symptoms while 61% were found incidentally. PPGs occur in up to 1:500 patients with arterial hypertension and can also be a secondary cause of diabetes. MI and acute or chronic cardiomyopathy are rare presenting features of PPGs. Takotsubo cardiomyopathy is the most common phenotype. In one acute MI study, Hispanic women were significantly more likely to receive delayed care as compared to non-Hispanic women, due to misinterpretation of symptoms by patients and providers. A meticulous history with formal interpretation in patients with limited English proficiency can lead to prompt diagnosis of this surgically curable cause of hypertension. Pheochromocytomas rarely present as acute myocardial infarction and stress cardiomyopathy. A high suspicion for PPGs must be maintained in patients with labile hypertension, cardiomyopathy and an incidental adrenal mass. History should be carefully revisited especially in patients with limited English proficiency. Presentation: 6/3/2024

Takotsubo syndrome with transient obstruction of the left ventricle outflow tract: A case report

BACKGROUND: Modern data have expanded our understanding of the pathogenetic mechanisms and clinical and laboratory findings in a patient with Takotsubo syndrome (TS). Nonetheless, its timely diagnosis and treatment remain challenging. All patients are initially treated according to the acute coronary syndrome protocol, with a "working" diagnosis of myocardial infarction without an obstructive lesion in the coronary arteries. However, the treatment of in-hospital complications of TS has its limitations and specific features. CLINICAL CASE DESCRIPTION: Herein, we have reported a case of TS that presented with the classic apical ballooning of the left ventricular apex, which had developed without an obvious stress factor, which is quite rare. The disease was complicated by the development of cardiogenic shock (CGS) and transient obstruction of the left ventricular outflow tract (LVOTO), which reportedly occurs in about 25% of the patients. CGS in patients with TS is a life-threatening complication and a challenging therapeutic problem, especially when it is also associated with a dynamic LVOTO. In such conditions, the only therapeutic option is mechanical circulatory support. However, in our patient, low doses of dobutamine were used to stabilize the patient’s hemodynamics. This treated produced a good therapeutic effect. CONCLUSION: Our case report findings emphasize the need for further research into the mechanisms of LVOTO development in TS, as well as the development of standardized approaches for the treatment of such patients in the acute phase of the disease.

Takotsubo Syndrome or Peripartum Cardiomyopathy? Depends on Who You Are Talking to.

Takotsubo syndrome (otherwise known as broken-heart syndrome or left ventricular apical ballooning) is a rare cause of reversible heart failure that predominantly affects postmenopausal women. It was first described by Japanese researchers in the 1990s and has become established as a differential for heart failure following a physically or psychologically stressful event. This was popularised by a spike in cases following natural disasters in Japan. As the recognition of takotsubo syndrome in the differential diagnosis for sudden, onset heart failure in a previously healthy individual has grown, so has the discussion concerning takotsubo in the peripartum period. Peripartum cardiomyopathy is a rare cause of reversible heart failure in the latter weeks of pregnancy and the postpartum period. Morbidity and mortality for both cardiomyopathies can be highly variable, ranging from complete recovery of cardiac function to life threatening arrhythmias and even death. This rapid review highlights the similarities between both cardiomyopathies and challenges the hitherto assumption that both takotsubo and peripartum cardiomyopathies are distinct entities that can easily be distinguished from one another. The implications of this are significant within the context of the behavioural aspects of diagnosis, treatment, and outcome.

Allergy, infarction, and stress cardiomyopathy: in-depth analysis of a complex clinical case report

Abstract Background Diagnosis of Kounis syndrome, an acute coronary syndrome associated with anaphylactic reactions, is challenging owing to the overlapping symptoms of myocardial ischemia. Takotsubo syndrome (TTS), characterized by stress-induced cardiomyopathy, may share pathophysiological mechanisms with Kounis syndrome and potentially coexist in the same patient. Case Presentation We present a case of a 63-year-old patient who developed an allergic reaction to contrast medium administration, leading to dyspnea and chest pain. Electrocardiography revealed a new-onset left bundle-branch block, and echocardiography indicated wall motion abnormalities with apical ballooning, suggestive of TTS. Coronary angiography displayed a chronic total occlusion of the right coronary artery. Laboratory tests revealed elevated inflammatory markers, supporting the diagnosis of Kounis syndrome and TTS. Conclusion This case highlights the challenges of diagnosing and managing type II Kounis syndrome associated with concurrent TTS. This underscores the need for tailored therapeutic interventions and comprehensive guidelines to address these complex conditions effectively.

Abstract Tu067: ROCK2 Specific Inhibition Prevents Isoproterenol Induced Takotsubo Cardiomyopathy in Mice

Takotsubo Cardiomyopathy (TCM) is an acute, life-threatening condition characterized by a drop in ejection fraction (EF) and apical ballooning of the left ventricle (LV). TCM is most frequently observed in women and is associated with an emotional or physical stressor. Recent work has demonstrated that the Rho kinase ROCK2 contributes to heart failure phenotypes in mice in other models of heart failure. The role of ROCK2 in TCM is unknown. We tested the hypothesis that ROCK2 inhibition attenuates isoproterenol (ISO)-induced TCM in mice. To induce TCM, male and female mice were given a single dose of 200mg/kg ISO, i.p. and cardiac function was assessed by conscious echocardiography. The effect of ISO overdose on acute heart failure over a 7-day time course was determined followed by an intervention study in which mice were treated with the ROCK2 specific inhibitor KD025/belumosudil (50mg/kg, i.p.) concurrent with heart failure induction. Though ISO induced a drop in EF in both sexes after 24 hours, females exhibited lower EF (46.64±3.11%) than males (68.36±2.62, p<0.0001) mirroring the increased prevalence of clinically defined TCM in females in humans. Female mice were used for the remaining experiments. Invasive hemodynamics revealed reduced contraction and relaxation (dp/dt max and dp/dt min) as well as an increased relaxation time constant Tau 24 hours after ISO injection. A time course study demonstrated that EF begins to normalize by Day 3 and is restored to baseline levels by Day 7. Importantly, ROCK2-specific inhibition prevented ISO-induced drop in EF, thinning of the LV wall, and LV volume expansion. Here, we demonstrate that female mice are more susceptible to ISO-induced cardiac dysfunction. Furthermore, we show that ROCK2 activation is necessary for the development of TCM in mice. These results suggest that FDA-approved KD025/belumosudil could potentially be repurposed for treatment in TCM.

Recurrence of Takotsubo Cardiomyopathy following Rigid Bronchoscopy: A Case Report

We report a case of a young male patient with a history of Takotsubo cardiomyopathy following polytrauma. On presentation, the patient had a tracheal stent placement for tracheal injury. The patient was again posted for removal of tracheal stent, by rigid bronchoscopy. During the procedure patient had a recurrence of cardiomyopathy, requiring inotropes and post-operative ventilatory support. 2D echo showed apical ballooning of the heart. The patient improved by inotropes and later on Lasix 10 mg IV. He was extubated after 2 days.

Development of a small animal model replicating core characteristics of takotsubo syndrome in humans.

Adequate animal models are necessary to understand human conditions, such as takotsubo syndrome (TS) characterized by the heart's transient regional wall motion abnormalities. This study aims to develop a reproducible, low-mortality TS model that closely mimics the human condition and addresses the limitations of existing models. We conducted six experiments using 309 Sprague Dawley rats, each approximately 300 g and aged 7-8 weeks. Initially, we replicated an established model using intraperitoneal isoprenaline injections. Subsequent experiments varied the doses and infusion durations of intravenous isoprenaline and assessed the effects of sex, strain, and breeder on the development of reversible akinetic segments. High-resolution echocardiography monitored the regional wall motion over 30 days to correlate with histological changes. Increasing the isoprenaline dose and the infusion time significantly enhanced akinesia (P < 0.01), resulting in pronounced apical ballooning observed in three-dimensional imaging. Akinesia peaked at 6 h post-infusion, with recovery observed at 24 h; most rats recovered from akinetic segments within 48-72 h. Optimizing the mode of administration, dose, and duration achieved a TS-like phenotype in 90% of cases, with a 16.7% mortality rate. Histological examinations confirmed that myocardial injury occurred, independent of apical ballooning. This study presents a refined TS model that reliably replicates the syndrome's key features, including morphological and electrocardiographic changes, demonstrating its transient nature with high fidelity and reduced mortality. The model's reproducibility, evidenced by consistent results across trials, suggests its potential for broader application pending further validation.

SCARY ECG IN TAKOTSUBO CARDIOMYOPATHY

Abstract Takotsubo cardiomyopathy (TTC) is characterized by a transient ventricular wall motion abnormality and shares common features with acute coronary syndrome (ACS) with a wide spectrum of triggers, such as both emotional or physical, activating common toxic catecholamines–mediated pathways. TTC might be associated with severe clinical complications. We report a case of a 74–year female patient with circulatory shock with mixed phenotype, distributive due to sepsis and cardiogenic due to TTC. The patient presented to the emergency department with severe hypotension, pathological qSOFA score and clinical and laboratory findings consistent with severe sepsis. ECG showed diffuse lambda ST–segment elevation, also called “shark fin”(fig.1). According to hemodynamically unstable scenario and ECG pattern, emergency coronary angiography was performed, showing absence of coronary artery disease(fig. 2). Echocardiography revealed severe LV systolic disfunction (EF 20–25%) with apical ballooning and severe systolic anterior motion (SAM) of the anterior mitral leaflet eliciting dynamic LVOTO with peak gradient greater than 90 mmHg; fig. 3) and severe MR. Patient was treated with cautious fluid administration, hemotrasfusion and empiric large spectrum antibiotic therapy. According to TTC working diagnosis, even if septic state was thought to contribute to cardiogenic shock, norepinephrine was not administered due to concerns for LVOTO and SAM. After overcoming of dramatic first phase and after hemodynamic steadiness was achieved, beta blockade and ACEi were progressively administered. Seriate transthoracic echocardiogram revealed progressive improvement of LV systolic function, regression of apical ballooning, SAM and LVOTO. ECG monitoring showed regression of ischemic ST elevation. ST elevation has been described in about 56% of TTC cases, however with amplitude tipically lower than in STEMI. Lambda–wave ST elevation has been rarely reported. Vasospasm, local intermittent microvascular constriction, catecholamine–induced metabolic toxicity, transmural systolic wall tension and its the mechano–electric feedback can explain scaring ECG–pattern. Despite its rare prevalence in TTC “shark fin” pattern appears to relate to adverse outcome and it should be used as an early marker of potential further clinical deterioration, suggesting more intensive monitoring to avoid delays in possible therapy escalation.

TAKOTSUBO SYNDROME AND SMALL BOWEL OBSTRUCTION: WHEN THE HEART–GUT AXIS GOES HAYWIRE

Abstract Case Report A 66 years old woman was admitted to our emergency department for the onset of intense epigastric pain, nausea and asthenia after breakfast. She had a history of hypertension, dyslipidemia, COPD and deep venous thrombosis with MTHFR gene mutation. Moreover, she had a positive family history for coronary artery disease (CAD). On arrival, she was apyretic, hemodynamically stable, complaining chest and persisting epigastric pain. A mild and diffuse abdominal tenderness was noted without peritoneal signs. The ECG showed sinus tachycardia, ST elevation (STE) in leads D1, aVL, V2 and V3 and ST depression in leads D3, aVR and V1. Blood test revealed a marked increase of PCR with leukocytosis and elevation of Hs–cTnI (840 ng/L) while serum electrolytes were normal. Bed–side echocardiography revealed apical and mid–ventricular akinesia with a severe reduction of left ventricular ejection fraction (LVEF). InterTAK score was 62 (62,6% probability of Takotsubo syndrome – TTS). An urgent coronary angiography (CA) revealed non– obstructive CAD, while ventriculography showed a typical apical ballooning and hyperkinetic base of the LV suggestive of TTS. Subsequently, the CT abdomen showed extra–luminal free fluid and a dilated proximal small bowel (SB) with air–fluid levels and a bubbly pattern of gas in the wall. These radiological findings were consistent with a mechanical SB obstruction, complicated by mesenteric venous thrombosis and intestinal pneumatosis. Exploratory laparotomy revealed SB necrosis as consequence of bridle–mediated obstruction and therefore an ileum resection was performed. The patient clinically improved post–operatively with a complete recovery of the LVEF. Discussion We described a rare presentation of SB obstruction which induced a TTS in a setting of severe psychophysical stress. The management of this emergency situation in which cardiac injury and acute abdomen occurred simultaneously can be challenging. The consulting cardiologist needs to quickly decide whether to prioritize the heart with urgent CA or the gastroenteric condition with surgery. Despite the likelihood of TTS can be high (even calculating InterTak score), new STE and positive troponins can’t be disregarded especially in patients with significant risk factors as seen in our case. Therefore, the strong evidence of a possible acute coronary syndrome may trump a life–saving treatment for SB obstruction.

The Science Behind Stress: From Theory to Clinic, Is Basal Septal Hypertrophy the Missing Link between Hypertension and Takotsubo Cardiomyopathy?

The modern theory of stress, initially proposed by Hans Selye in 1956, signifies an important development in our understanding of this phenomenon. Selye’s The Stress of Life serves as a foundational book for subsequent scientific questions. In this article, we focus on a comprehensive look at stress and use a literature review to explain its theoretical foundations as well as its clinical equivalent. Our research focuses on the complex mechanisms of stress, with a particular emphasis on the consequences of cardiac remodeling and adaptation processes. Myocardial remodeling might be seen as a response to increased stress in acute or chronic situations. Stressed heart morphology (SHM) is a very interesting description representing basal septal hypertrophy (BSH), which is detectable in both acute emotional stress and chronic stress due to increased afterload in hypertension. Acute stress cardiomyopathy (ASC) and hypertension in the same individuals could be clinically linked. Also, in this report, we mention the geometric and functional similarity of the left ventricle (LV) septal base in both acute and chronic clinical situations. Therefore, cardiac imaging methods are crucial to assessing LV segmental aspects in ASC patients. We propose a new paradigm that ASC may develop in hypertensive patients with SHM. We document the segmental progression of microscopic LV remodeling using a third-generation microscopic ultrasound and note that BSH takes a longer time to occur morphologically than an acutely developed syndrome. However, the majority of ASC events have a predominant base, and the absence of segmental remodeling details, including BSH and cardiac decompensation with apical ballooning, on echocardiographic reports may mask the possible underlying hypertensive disease. In fact, beyond ASC cases, previously undiagnosed hypertension is very common, even in developed countries, and is associated with masked target organ damage.

Comparing clinical profiles, in-hospital complications and one-year cerebrovascular events in typical and midventricular TTS-results from a retrospective study between two third-level centers

Abstract Funding Acknowledgements None. Background Apical ballooning is considered the typical form of Takotsubo syndrome (TTS) and occurs in about 75-80% of cases. Midventricular (MV) is the most frequent atypical variant and represents about 15% of TTS. Clinical and analytical characteristics, early complications and the risk of cerebrovascular events (CVEs) between these two specific groups are poorly studied. Purpose of the study To investigate the clinical profile, laboratory variables, in-hospital complications and one-year CVEs between typical and MV variants of TTS. Methods we retrospectively examined the patients admitted to two third-level hospitals with a diagnosis of TTS. A total of 248 TTS met InterTAK diagnostic criteria. Clinical features, myocardial enzymes, echocardiographic variables, early complications and one-year CVEs were assessed. Results Of 248 patients diagnosed with TTS, a total of 205 (83%) patients presented with typical and 43 (17%) with MV variant of TTS. Patients with MV form were younger (age mean ± SD 68 ± 12 vs 74 ± 11 years, p value = 0.002) and had a lower incidence of hypertension (46% vs 73%; p value &amp;lt; 0.001) than those with apical variant. On admission, patients with MV form presented a lower degree of left ventricular dysfunction (EF mean ± SD, 44 ± 9% vs 41 ± 9%, p value = 0.018) and a tendence not to present left ventricular outflow tract obstruction (LVOTO) (0 vs 9%, p value = 0.049). Lower N-terminal pro-brain natriuretic peptide (NT-proBNP) levels on admission (median [IQR], 881 [99 – 3049] pg/mL vs 3466 [677 - 9067] pg/mL, p value &amp;lt;0.001) and at peak (3150 [947- 4437] pg/mL vs 4622 [1886 - 13163] pg/mL, p value = 0.005) were observed in MV group compared to the typical form. In-hospital cardiovascular (CV) complications were frequently observed (46% in the overall population) and appeared to be more frequent in the typical variant (51% vs 33%, p value= 0.035); in particular, we reported a higher prevalence of AF (16% vs 2%, p value = 0.022). The number of CS and VT cases is remarkable in both the subgroups (13% vs 7%; 5% vs 2%), with a higher prevalence in the typical form, even if not reaching a statistically significant difference between the two groups (p= 0.437; p= 0.695). No significant differences were observed in LV thrombosis, and in on admission and one-year CVEs between the two groups, although with a higher prevalence in the typical variant (respectively 3 vs 0, 10 vs 1 and 5 vs 0). Conclusions MV TTS presents some differences in clinical characteristics, analytical values and echocardiographic parameters compared to the typical variant. In-hospital CV complications are remarkable, and more frequently observed in typical variant, although not reaching a statistically significant difference in CS and VT. Similarly, more CVE were observed in the typical TTS group, although in the absence of a statistical significance. The importance of close monitoring in the acute phase is confirmed for both variants under study.

Immune Activation Promotes Cardiac Remodeling in a Mouse Model of Takotsubo Cardiomyopathy

Takotsubo Cardiomyopathy (TCM) is an acute, life-threatening condition characterized by a drop in ejection fraction (EF) and apical ballooning of the left ventricle (LV). TCM is most frequently observed in women and is associated with an emotional or physical stressor. Importantly, with medical intervention, cardiac dysfunction is transient, and EF is often restored over weeks to months. Despite this, patients who experience TCM are at an increased risk of additional cardiovascular events and premature mortality. The precise etiology of TCM is unknown but a wave of excess circulating catecholamines is thought to be a trigger. Furthermore, the cause for increased cardiovascular risk post-TCM is unknown. The goal of this study is to understand how the immune system may contribute to TCM and the associated cardiovascular event risk. To induce TCM, mice were given a single dose of 200mg/kg isoproterenol (ISO), i.p. and cardiac function was assessed by conscious echocardiography (ECG). An initial study compared the effect of ISO between sexes (n=4-6). Though ISO induced a drop in EF in both sexes after 24 hours (p&lt;0.001 compared to vehicle (Veh)), females exhibited lower EF (46.64±3.11%) than males (68.36±2.62%, p&lt;0.0001). This mirrors the increased prevalence of clinically defined TCM in females in human populations. For this reason, female mice were used for the following experiments. A time course study demonstrated that EF begins to normalize by Day 3 (78.78±2.70 v 90.80±1.00%, p&lt;0.001) and is restored to baseline levels by Day 7 (90.65±1.17%). Flow cytometry was used to identify changes in immune cell populations in the heart on Days 0, 1, 3 and 7 (n=4-5). Neutrophils and inflammatory monocytes increased on Day 1, returning to baseline by Day 3. Dendritic cells and macrophages were elevated on Day 3 post-ISO, with a specific increase in CCR2+ TIM4- recruited inflammatory macrophages (p&lt;0.0001). Across all subsets, the number of immune cells returned to baseline levels by Day 7. Due to the robust immune response observed, we tested the specific hypothesis that transfer of immune cells from mice who have experienced TCM would induce cardiac dysfunction in naïve recipient mice. Donor mice were treated with either Veh or ISO and 1 day later splenocyte isolation and transfer was performed. Importantly, transfer of splenocytes from mice who had TCM induced a significant drop in EF the following day in the recipient mice (86.30±1.08%, p=0.001, n=10) concurrent with an increase in LV inner diameter and volume during systole. A final study tested the hypothesis that a history of TCM would increase risk for future cardiovascular disease. Veh or ISO-treated mice were allowed to recover for 10 days. Tail-cuff plethysmography showed no significant difference in baseline blood pressure and minipumps were implanted to deliver a constant infusion of Angiotensin II (Ang II, 140ng/kg/min). Mice with a history of TCM exhibited higher blood pressures compared to controls (135.11±3.32 v 116.9±6.41mmhg, n=6/9, p&lt;0.05) by week 2 of Ang II infusion. These results together demonstrated that TCM is associated with a robust immune response and points to a possible causal contribution of immune activation to the cardiac dysfunction observed in TCM. Furthermore, a history of TCM promotes a hypertensive phenotype, but additional studies are needed to test whether this is through immunological mechanisms. AHAPOST837441 DJF, 19EIA34480023-MSM, and 1R01 HL161212-MSM. This is the full abstract presented at the American Physiology Summit 2024 meeting and is only available in HTML format. There are no additional versions or additional content available for this abstract. Physiology was not involved in the peer review process.

A Comparative Analysis of Positive and Negative Stimuli for Takotsubo Cardiomyopathy: A Pooled Analysis of Two Studies and a Systematic Review.

Takotsubo cardiomyopathy (TTC) is characterized by transient myocardial dysfunction triggered by both negative and positive emotional experiences, known respectively as broken heart syndrome (BHS) and happy heart syndrome (HHS). Despite the scarcity of comparative analyses between HHS and BHS in the literature, our pooled analysis, incorporating two retrospective registry analyses of 1395 TTC patients (57 HHS and 1338 BHS), reveals that while BHS is more prevalent, both conditions exhibit similar clinical presentations and outcomes. Statistical analyses, utilizing binary random effects models, indicate that diabetes mellitus is less common in HHS patients and serves as a predictor for BHS. Furthermore, there are differences in cardiac imaging between the two groups; individuals with HHS have higher odds of experiencing midventricular ballooning, whereas those with BHS are more likely to have apical ballooning. These findings highlight the similarities in clinical features and outcomes between HHS and BHS, while also illustrating distinct imaging profiles. The study emphasizes the need for future prospective studies to delve deeper into the implications of these TTC subtypes, offering valuable insights into their comparative aspects and underlying mechanisms.

Carbon monoxide poisoning manifesting with rhabdomyolysis, Takotsubo syndrome, and skin lesion: A case report

Carbon monoxide (CO) poisoning is characterized by non-specific and protean clinical manifestations, exhibiting a highly variable presentation. We present a case of an 83-year-old female Alzheimer&amp;rsquo;s patient, a non-smoker, who was found unconscious in her wheelchair by her caregiver at home. The heating in the apartment was powered by liquefied petroleum gas. On admission to the emergency department, her vital signs were normal, but she was unconscious and slightly dyspneic. The examination revealed red-colored skin lesions in the submammary area, where the wheelchair safety belt was firmly fastened. The rest of the physical examination results were unremarkable. The carboxyhemoglobin level was 23%, and there was an increase in creatine phosphokinase and troponin I levels. On the 2nd day of hospitalization in the emergency ward, the electrocardiogram revealed negative T waves in the V1&amp;ndash;V6 leads, while the bedside echocardiogram revealed apical ballooning of the left ventricle. The myocardial perfusion examination yielded a negative result for myocardial ischemia. In the management of patients with CO poisoning, it is important for emergency physicians to assess the presence of multiple organ and tissue disorders. Consequently, the patient was diagnosed with CO poisoning with skin, skeletal, and cardiac muscle involvement.

Takotsubo Cardiomyopathy and Autoimmune Disorders: A Systematic Scoping Review of Published Cases.

Takotsubo cardiomyopathy (TCM) features transient left ventricular apical dysfunction or ballooning. The underlying mechanism remains elusive; however, evidence suggests the role of different physical and psychological stressors. We systematically reviewed patients presenting with TCM and autoimmunity to explore the link between the two conditions. We applied the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) to report this review. Using keywords related to autoimmune/immune-mediated diseases and TCM, we searched PubMed, Scopus, and WOS in March 2022. The final results were added to a data extraction sheet. Data were analyzed by SPSS version 26.0. Our search yielded 121 studies, including 155 patients. Females were considerably predominant. Most patients had a history of autoimmune disease, and almost a third had a history of cardiovascular disease. Dyspnea and chest pain were the most common chief complaints. More than 70% of patients had experienced physical stress. Myasthenia gravis, systemic lupus erythematosus, and multiple sclerosis were the most frequently reported autoimmune diseases. There were similarities in age and sex compared to classic TCM. TCM should be considered as a differential diagnosis for ACS, especially in patients with a positive background of autoimmunity. A precise reporting system is required for further studies.

Kiosk 6Q-FA-09 - Apical Ballooning: Differentiating the Similar Imaging Features of Takotsubo and Hypertrophic Cardiomyopathy

Kiosk 6Q-FA-09 - Apical Ballooning: Differentiating the Similar Imaging Features of Takotsubo and Hypertrophic Cardiomyopathy

Takotsubo Cardiomyopathy: Patients Characteristics, Mortality, and Clinical Significance of Left Ventricular Outflow Tract Gradient, Retrospective Study.

Takotsubo cardiomyopathy (TC) is a reversible left ventricular systolic dysfunction with apical ballooning. Left ventricular outflow tract (LVOT) obstruction may develop in these cases due to hyperdynamic state of the left ventricle. Limited data are available on the prevalence of LVOT gradient in TC and its association with patient outcomes and mortality. Data were collected retrospectively for patients diagnosed with TC in a single tertiary center, demographic information, blood analysis results, and imaging finding including ejection fraction, and LVOT gradient was obtained from medical records. Additionally, medical treatment and outcome during hospitalization were extracted. Follow-up was conducted through cardiology clinic or phone contact. A total of 59 patients diagnosed with TC were reviewed during hospitalization, and 40 patients were followed up after discharge by phone contact and cardiology clinic. Most patients were female (91.5%), and nonsignificant coronary artery disease was present in 16.9% of patients. Approximately two-third of the patients had a reduced ejection fraction on admission, and only two patients (5.4%) continued to have reduced ejection fraction on echocardiography follow-up within a period of 2-14 days. LVOT gradient was present in 17 patients (28.5%); patients with preserved ejection fraction had a higher probability of having an LVOT gradient. However, there was no association between LVOT gradient and shock or mortality. Four patients (6.7%) experienced 30-day mortality, while all-cause mortality was reported in eight patients (13.5%) over the follow-up period (mean (±SD) 20.8 months ± 16.2). LVOT obstruction may occur in TC patients; it has no correlation with shock or mortality. However, determining whether there is a gradient is important for deciding on specific treatment approach.

TAKOTSUBO SYNDROME

Takotsubo syndrome, also known as Takotsubo cardiomyopathy, stress-induced cardiomyopathy, transient apical ballooning and broken heart syndrome, is a disease characterized by transient regional left ventricular systolic dysfunction. It is usually determined by emotional or physical stress. Even though it was thought to be a self-limiting condition, Takotsubo syndrome is now known to be associated with important short and long-term morbidity and mortality. Takotsubo syndrome affects 2-3% of all patients and 5-6% of female patients presenting with acute coronary syndrome (frequently women in the sixth decade). The Takotsubo syndrome cases are mostly preceded by acute emotional or physical triggers such as: family death, financial loss, anxiety, excessive work, domestic abuse, anxiety, fear for medical procedures, severe pain, sepsis, post surgeries, and cancer. Diagnosis of Takotsubo syndrome can sometimes be difficult due to clinical manifestations similar to acute myocardial infarction. Myocardial necrosis biomarkers (Troponin I, Troponin T and Creatinin kinase) are elevated, with values comparable to those in patients with acute myocardial infarction. Transthoracic echocardiography usually shows akinetic or dyskinetic apical and mid-ventricular segments of the left ventricle compared to the hyperkinetic basal segments (“apical ballooning” aspect) and left ventricle systolic dysfunction. The positive diagnosis of Takotsubo syndrome is made on coronary angiography, normal or non-obstructive coronary artery disease

Myocardial strain changes over a 1-month follow-up in Takotsubo syndrome: a case report

Among various diagnostic methods, echocardiography (EchoCG) is most often used to identify Takotsubo syndrome. Left ventricular apical ballooning and the absence of permanent local contractility disturbances makes it possible to confirm the diagnosis. Currently, the available literature provides insufficient data on longitudinal strain (LS) of various cardiac chambers in this condition. The current case report demonstrates complete restoration of left heart LS within 1 month with its initial significant decrease.