Apical Wall Motion Abnormalities Research Articles

Echocardiographic wall motion abnormalities and mortality reported in 492,338 individuals

Abstract Background The prevalence of abnormal regional left ventricular function in the setting of myocardial ischaemia is incompletely studied, along with the relative frequency of individual wall motion abnormalities (WMA). We examined the prevalence and distribution of regional WMA in adults being investigated with echocardiography, and the association with mortality. Methods Routinely acquired echocardiographic reporting data and individually linked survival profiles were extracted from the Australia-wide, multicentre National Echocardiography Database of Australia. By applying natural language processing (NLP) to the cardiologist’s report of left ventricular (LV) function, we examined global and regional LV dysfunction. Results 492,338 (age 61.9± 17.9) individuals (255,697 men aged 60.5±17.1 and 236,341 women aged 60.9±18.3 years) could be evaluated. 57,180 (17.6%) individuals were reported to have abnormal wall motion (39,346 men aged 69.0+/-13.4 yrs and 17,834 women, 71.3+/-14.3 yrs). The presence of a WMA was associated with increased left atrial volumes (LAVi: 55.5±36.4 vs 40.9±27.5 ml/m2 for women) , impaired LVEF (50.8±15.1% vs 61.1±12.2% for women), impaired diastolic function (E` 6.64±2.21 vs 8.25±2.86 cm/s for women), and higher pulmonary artery pressure (eRVSP 36.2±11.5 vs 32.5±10.7 mmHg) . Most, but not all individuals had a history of myocardial infarction with or without revascularisation. An inferior WMA was the commonest, with 18,638 WMA reported (4.7%), followed by apical WMA (19,682; 3.4%), lateral WMA (16,976; 2.9%), septal WMA (15,722; 1.7%) and anterior WMA in 9,432 (1.6%). In men, long-term all-cause mortality for WMA was 40.5% (compared to 23.3% without), and in women 42.7% (vs 20.5%). These WMA observations were magnified in those >65 years and with impaired systolic function. The presence of akinesis/dyskinesis/aneurysm of any wall fared worse than hypokinesis (OR 1.34 CI:1.22-1.44 P< 0.001 for Inferior WMA). Females with a WMA had less mortality (OR 0.80 CI: 0.74 – 0.85; P, 0.001), and any revascularisation was protective (OR 0.76 CI 0.46 – 0.69 P<0.001). Conclusion WMA are reported in men at greater than twice more frequently than women, and overall contribute almost a fifth of echocardiographic reports. The presence of a WMA is associated with impaired LV systolic and diastolic function, signs of increased LV filling pressure and pulmonary pressure, and high long-term mortality that is partially ameliorated by revascularisation. Prognosis is affected by the presence, extent and severity of WMA.

Takotsubo Cardiomyopathy in the setting of Urosepsis

Takotsubo cardiomyopathy is a rare cardiac condition associated with transient left ventricular apical wall motion abnormalities in association with stress but without any signifcant coronary artery disease. We present a case of takotsubo cardiomyopathy presenting as acute pulmonary edema in the background of urosepsis.

Left ventricular longitudinal strain: a useful tool in the evaluation of patients with Takotsubo syndrome

Abstract Funding Acknowledgements Type of funding sources: None. Introduction In contrast with the usual type of Takotsubo syndrome (TS), where apical wall motion abnormality occurs, the less common patterns (mid-ventricular, basal, and focal) are often misdiagnosed. Purpose In this retrospective study we examined the role of global (GLS) and territorial longitudinal strain with speckle tracking in the evaluation of patients with TS. Methods Patients with TS were examined at the echocardiography laboratory of our general hospital, from August 2019 until August 2022. Left ventricular ejection fraction (LVEF) and GLS were calculated and territorial longitudinal strain was assessed. Results Out of 21 patients with TS (19 females), of median age 67.5 years (range 33.0 – 87.0 years), 11 (52.4%) had apical distribution, 6 (28.6%) mid-ventricular, 2 (9.5%) basal and 2 (9.5%) focal. Of those, 3 were excluded from the study due to insufficient echocardiographic image quality. Patients with apical pattern had median LVEF 37% (range 23–51%) and GLS −7.6% (−5.8 to −12.5%), patients with mid-ventricular pattern had median LVEF 40% (35–50%) and GLS −14.2% (−9.3 to −16.5%) and patients with basal pattern had median LVEF 52% (47–56%) and GLS −16.5% (−14.6 to −18.4%). In the first case of focal distribution, wall motion abnormality was found at the anterior septal wall, and LVEF was calculated 46% and GLS −12.8%. In the second case, abnormality was found at the inferoposterior wall and LVEF was calculated 56% and GLS −17.3%. Patients with apical TS had median strain of basal territory −11.7%, mid territory −3.7% and apical territory +3.6%. Patients with mid ventricular TS had median strain of basal territory −10.2%, mid territory −6.5% and apical territory −19.7%. Patients with basal TS had median strain of basal territory −4.3%, mid territory −16.4% and apical territory −29.1%. Conclusion GLS and territorial longitudinal strain reflect the reduction in left ventricular systolic function and the distribution of wall motion abnormalities in patients with TS, which further supports the initial diagnosis.

P312 TAKOTSUBO SYNDROME DURING INFECTIVE ENDOCARDITIS: AN UNUSUAL COMBINATION

Abstract A 66–year–old woman presented to medical attention for low back pain, weight loss and evening fever for about 2 weeks, with concomitant mood deflection. Blood cultures were positive for Streptococcus mutans. Lumbar spondylodiscitis was found on spinal MRI and splenic infarction on abdominal ultrasound. The echocardiogram revealed the presence of vegetations on the aortic valve, which was severely regurgitant, and on the tricuspid valve, which was moderately regurgitant, in a setting of preserved biventricular dimensions and function. The patient was diagnosed with infective endocarditis, complicated by systemic embolization. The hospital stay was complicated, despite the appropriate antibiotic therapy, with acute pulmonary edema and cardiogenic shock, with a sudden worsening of the left ventricular function which became severely reduced, in the presence of an "apical ballooning" appearance. Anterior T–wave inversion with prolongation of the QT interval was documented on the electrocardiogram. Coronary lesions were excluded by coronary CT scan. According to the InterTAK criteria, the patient achieved a score of 80, suggestive of a high probability of Takotsubo syndrome. In the following days, thanks to continuous infusion of diuretics and inotropic support, a hemodynamic compensation was obtained; there was a progressive recovery of the left ventricular function and of the apical wall motion abnormalities, with suspension of the inotropic support and reduction of the dosage of the diuretic. We concluded for Takotsubo syndrome in the setting of acute infective endocarditis. The patient, with a stabilized clinical picture, finally underwent cardiac surgery to replace the aortic and tricuspid valves without complications. Takotsubo syndrome (TS) is a condition characterized by a transient impairment of left ventricular function and kinetics, typically triggered by physical or emotional stress. In the literature only four cases of concomitant endocarditis and TS are reported, in which other triggers are recognizable (recent surgery, cerebral involvement with embolization or meningitis). In our case, there are no other apparent triggers other than endocarditis. Endocarditis could therefore represent in itself a new trigger for TS or even manifest, from the beginning, with a TS.

Direct oral anticoagulants compared to vitamin K-antagonists in patients with left ventricular thrombus

Abstract Background/Introduction In the setting of left ventricular thrombus (LVT), direct oral anticoagulants (DAOC) are poorly studied. Current European guidelines recommend treatment with Vitamin K antagonists (VKA) for 6 months. So far, several observational studies reported similar efficacity and safety of DOACs, compared to VKAs. Controversial findings were found in one big cohort, where higher stroke rates were reported among patients treated with DOAC compared to VKA, what raised concerns about the efficiency and safety to use DOACS in the setting of LVT. Purpose This retrospective multicenter study compared thrombus resolution and clinical outcomes of patients with LVT treated with DOACs or VKAs. Methods From an echocardiography database of three teaching hospitals in Switzerland, patients diagnosed with LVT between 2015 and 2021 were identified. All echocardiograms and outcomes were reviewed by independent physicians. Thrombus resolution rate and clinical outcomes were compared according to the underlying anticoagulation regimen. Results Overall, 101 patients (17.8% females, mean age 63.3±13.2 years) were included. Among those, 50.5% had a recent myocardial infarction, 38.6% chronic ischemic heart disease and 10.9% suffered from non-ischemic cardiomyopathy. At hospital discharge, 48 (47.5%) were treated with DOACs and 53 (52.5%) with VKAs. Initial left ventricular ejection fraction was 38±13%. 93.1% patients presented with apical wall motion abnormalities, mean wall motion score index was 1.91±0.39. Initial thrombus size was comparable in both groups (table 1). Median follow-up was 799 (354; 1236) days and the clinical composite endpoint combining stroke, systemic embolism, bleedings, myocardial infarction and death was comparable in the VKA (22.6%) and DOAC (27.1%) group, respectively. There was no difference in major (4% vs. 6.3%) and minor (13.5% vs. 4.3%) bleeding events, neither for stroke and systemic thromboembolism (14.3% vs 14.9%) or death (11.3% vs 8.5%). Thrombus resolution rate after 1 year was similar in the VKA and DOAC group (75.5% vs. 76.7%), but early thrombus dissolution within the first month was faster in the VKA arm (p=0.049). In each group, 3 subjects had thrombus recurrence after cessation of anticoagulation. Conclusion Among patients with LVT, DOACs appear to be a safe and effective alternative to vitamin K antagonists, but thrombus seems to dissolve slower in the first month. An adequately powered randomized trial is needed to confirm these findings. Funding Acknowledgement Type of funding sources: None.

Spectrum of radionuclide perfusion study abnormalities in takotsubo cardiomyopathy

BackgroundTakotsubo (stress) cardiomyopathy (TCM) is characterized by transient apical left ventricular dysfunction precipitated by emotional or physical stress. Its presentation makes it difficult to differentiate from an acute coronary syndrome. A suggestive echocardiogram plus normal coronary angiography most often are used for diagnosis. Radionuclide perfusion study (RPS) findings in TCM, including by positron emission tomography (PET), have been poorly characterized. Methods and ResultsIntermountain Healthcare electronic medical records were searched from 2009 to 2019 for patients with a discharge diagnosis of TCM, stress CM, or takotsubo syndrome. 16 TCM patients with an RPS, including by PET in 8, were identified: 13 (81%) were women; age averaged 72 years (50-89 years); 14 had an identified stressor. TCM diagnosis was definite in 11 and probable/possible in 5. RPS was abnormal in 11, with 9 showing an apical perfusion deficit, whereas angiography in 14 showed normal coronaries in 12 and non-obstructive disease in 2. Echo ejection fraction averaged 41% (29%-60%); an apical wall motion abnormality was present in 14 (88%). Troponin elevations were noted in 14/15. The presenting ECG was abnormal is 14, frequently showing ST-T-wave abnormalities. 13 patients were discharged on a beta-blocker. Follow-up echo (in 12) showed recovered ejection fraction in 9 and recovered apical wall motion in 11. ConclusionsDespite having normal or non-obstructive epicardial coronary arteries on angiography, TCM patients frequently present with apical wall motion abnormalities and matching RPS perfusion defects. These findings suggest microvascular abnormalities, whose pathophysiology, temporal course, and clinical implications should be the subject of further investigation.

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients After Anterior Myocardial Infarction

BackgroundThe presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction (MI). Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential. We aimed to compare the two-dimensional echocardiography (2DE), contrast-2DE and real-time three-dimensional echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior. MethodsThe study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (< 40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and magnetic resonance imaging (MRI) were performed on all patients within one month after anterior MI. ResultsTransthoracic 2DE detected thrombi in 29 patients, contrast-2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast-2DE and RT-3DE, respectively. ConclusionsWe found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT.

Impact of Multimodality Imaging on the Diagnosis of Left Ventricular Apical Thrombus in Patients after Anterior MI

Abstract Background The presence of the left ventricle (LV) apical thrombus is one of the most critical complications of anterior myocardial infarction. Due to the high risk of systemic embolization, the determination of LV apical thrombus (LVAT) is essential. Purpose We aimed to compare the Two-Dimensional Echocardiography (2DE), contrast-2DE and Real-time Three-Dimensional Echocardiography (RT-3DE) in the diagnosis of LVAT and determine which imaging modality is superior. Methods The study was designed as a prospective cohort study, and 161 patients were included. Patients with low ejection fraction (&amp;lt;40%) and LV apical wall motion abnormality (severe hypokinetic, akinetic or dyskinetic) were included. 2DE, contrast-2DE, RT-3DE, and Magnetic Resonance Imaging (MRI) were performed to all patients within one month after anterior MI. Results Transthoracic 2DE detected thrombi in 29 patients, contrast 2DE detected thrombi in 33 patients, RT-3DE detected thrombi in 32 patients, and MRI detected thrombi in 28 patients. While MRI is accepted as the gold standard for non-invasive imaging, the specificity of detecting thrombus with 2DE is 90%, and the sensitivity is 57%, contrast-2DE had 82% sensitivity and 92% specificity for the detection of LVAT. The specificity for detecting thrombus with RT-3DE is 93%, and the sensitivity is 85%. Accuracy was 84%, 90% and 92% with 2DE, contrast 2DE and RT-3DE, respectively. Conclusion We found that RT-3DE was more sensitive and more specific than 2DE and contrast-2DE in the diagnosis of LVAT. The diagnostic accuracy of RT-3DE was higher than 2DE and contrast-2DE for LVAT. Funding Acknowledgement Type of funding sources: None.

Cerebral vasospasm, intracardiac clot, wellens syndrome, and popliteal vein aneurysm in a hypercoagulable state in lassa fever

Background: Lassa fever could precipitate a condition of hypercoagulable state with multiple organ involvement. We report an unusual presentation of cerebral vasospasm, intracardiac clot, Wellens syndrome, and popliteal vein aneurysm in a case of Lassa fever. We demonstrate the use of noninvasive imaging in the diagnosis and management of hypercoagulable state in a first case presentation in Lassa fever. Methods: We present a 53-year-old Nigerian woman, with a high-grade fever (39°C) that was associated with chills, headaches, insomnia, anxiety, chest pain, diaphoresis, palpitation, general weakness, muscle aches in all extremities, muscle cramps, dizziness spells, hyperacusis, nausea, vomiting, diarrhea, hematochezia, and abdominal pain. She admitted that her home is infested with rodents. Physical examination revealed severe anemia. Laboratory tests including blood sample analysis and biochemistry were conducted. Lassa fever was confirmed using Lassa virus-reverse transcription-polymerase chain reaction tests. Electrocardiography (ECG), two-dimensional echocardiography, venous duplex ultrasound of the leg veins, and transcranial Doppler ultrasound were performed. Results: Blood tests showed electrolyte imbalance and hypertriglyceridemia. Ultrasound tests revealed intracardiac clots with dyskinetic apical septal wall motion abnormality, saccular aneurysm with popliteal venous thrombosis of the right leg popliteal vein, and cerebral vasospasm of the right internal carotid artery due to cardiogenic microemboli. ECG demonstrated Wellens syndrome. The patient was successfully treated with intravenous ribavirin, whole blood transfusion, broad-spectrum antibiotics, isosorbide dinitrate, pentoxifylline, metronidazole, antimalarial, dexamethasone, erythropoietin, anticoagulants (low-molecular-weight heparin and warfarin), and supportive care. Conclusion: Noninvasive ultrasound modalities were useful for early detection and treatment of hypercoagulable state in Lassa fever.

A RARE PRESENTATION OF APICAL HYPERTROPHIC CARDIOMYOPATHY

SESSION TITLE: Fellows Cardiovascular Disease Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Apical Hypertrophic Cardiomyopathy (AHCM) is an uncommon morphological variant of HCM in which the hypertrophy of the myocardium predominantly involves the apex of the left ventricle. These patients do not have Left ventricular outflow tract (LVOT) obstruction but may have midventricular obstruction. Most patients with AHCM present with no or mild symptoms, although presentation with angina, HF, myocardial infarction, atrial fibrillation (AF), or ventricular fibrillation has been reported. CASE PRESENTATION: A 49yr old male with PMHx of HTN who presented to ED with VFib arrest, shock x1. Patient was sleeping in bed when his wife noticed him snoring and suddenly stopped breathing, gasped for breath. CPR for ∼10 min. EMS arrived and the patient was found to be Vfib and he was shocked . ROCS was achieved and the patient was communicative enroute, never intubated and was hemodynamically stable. Family history was significant for CAD in mother. One sibling with CABG. and another with "Arrhythmia and thick heart muscle". Initial EKG with giant/ deep T inversions in V3-V6 and early repolarization changes in V1,V2 (Figure1). Patient underwent emergent cardiac cath which showed clean coronaries and normal ejection fraction. Spade sign was observed on ventriculogram which is characteristic of Apical Hypertrophic Cardiomyopathy (AHCM)(Figure2). AICD was placed on hospital day (HD) 2 for secondary prevention of cardiac arrest. Patient was discharged on HD 4. DISCUSSION: Typical features of apical HCM include•Audible and palpable fourth heart sound, reflecting impaired LV relaxation•"Giant” negative T waves on electrocardiogram (ECG), particularly in the left precordial leads•"Spade-like” configuration of the LV cavity at end-diastole on imaging•Associated apical wall motion abnormalities which may include hypokinesis and aneurysm formation CONCLUSIONS: APCM is an uncommon and underappreciated. High index of suspicion and early recognition on EKG,echocardiography, left ventriculography, most accurately with CMR will aid in early diagnosis, appropriate close follow-up and management. The long-term prognosis for some morphologic subgroups of AHCM might be better than for other HCM phenotypes. However, up to one fourth of individuals can develop significant morbidity with heart failure, apical fibrosis, apical aneurysm formation, ventricular tachycardia and cardiac arrest. Periodic lifelong follow-up is recommended for asymptomatic patients with AHCM. Family screening should be considered. Symptomatic patients are initially treated with medical therapy; however, since nearly all patients with apical HCM do not have evidence of LVOT or mid cavity obstruction, septal reduction therapy is almost never an option in those patients. Risk stratification for ventricular tachyarrhythmias and SCD is the same as for other patients with HCM and should be considered for prophylactic AICD placement(Figure 3). Reference #1: Maron BJ. Clinical course and management of hypertrophic cardiomyopathy. N Engl J Med. 2018; 379:655–668. Reference #2: Stainback RF. Apical hypertrophic cardiomyopathy. Tex Heart Inst J. 2012;39(5):747-749. Reference #3: Rowin EJ, Maron MS, Chan RH, et al. Interaction of adverse disease-related pathways in hypertrophic cardiomyopathy. Am J Cardiol 2017;120:2256-2264. DISCLOSURES: no disclosure on file for Byoungchul Kim; No relevant relationships by Ratnam Santoshi, source=Web Response No relevant relationships by Rajendra Shetty, source=Web Response

75-Year-Old Woman With Chest Pain and Shortness of Breath

75-Year-Old Woman With Chest Pain and Shortness of Breath

332 Echocardiographic Wall Motion Predictors of Apical Left Ventricular Thrombus Formation

Left ventricular thrombus (LVT) after anterior ST elevation myocardial infarction (aSTEMI) almost usually forms in the left ventricular (LV) apex, suggesting that apical regional wall motion abnormalities (RWMA) are fundamental in its pathogenesis. We sought to evaluate the role of severe RWMA in LVT formation after aSTEMI. 27 consecutive patients with LVT on inpatient transthoracic echocardiography (TTE) imaging after aSTEMI between January 2010 and September 2017 were retrospectively identified. Cases were matched by age and sex to 27 controls. TTE images for all patients were assessed by a blinded examiner and all 17 LV segments were graded to detect presence of severe RWMA (defined as akinetic, dyskinetic or aneurysmal LV segments). Results were analysed using univariate analysis and reported as odds ratios (OR) with 95% confidence intervals (CI). Severe RWMA in the mid anteroseptal (OR=7.19, CI=1.95-26.51, p=0.003) and mid anterior (OR=5.34, CI=1.45-19.64, p=0.012) segments were associated with LVT. Although all cases had apical segment RWMAs, severe RWMA in the apical septal (OR=1.56, CI=0.24-10.19, p=0.64), apical lateral (OR=1, CI=0.33-3.02, p=1), apical anterior (OR=1.82, CI=0.39-8.51, p=0.45), apical inferior (OR=0.47, CI=0.16-1.40, p=0.18), and apical cap (OR=1.18, CI=0.38-3.60, p=0.78) were not associated with LVT. While apical RWMA was present in all patients with LVT, only severe RWMA in the mid anteroseptal and mid anterior segments were associated with presence of LVT. This suggests that although apical RWMA are necessary for LVT formation, larger infarct size with mid segment extension are more predictive of LVT.

Takotsubo (stress) cardiomyopathy in childhood.

Takotsubo cardiomyopathy (TC) is a significant cause of acute heart failure in adults. However, triggering factors, ECG and echocardiographic findings, and prognosis of TC have not been well studied in children. Therefore, this study aimed to evaluate the demographic characteristics, signs and symptoms, laboratory findings, and prognosis of children with TC. We analyzed demographic characteristics of childhood TC cases (aged < 18 years) treated at our university hospital from 2014 to 2019. The triggering factors of TC; outcomes of the disease; and laboratory, ECG, and echocardiographic findings at presentation were also examined. A total of 17 patients (mean age 9.71 ± 5.03 years, 52.9% female) were included in the study. Chest pain, palpitation, and dyspnea were the most common presenting symptoms. The most common triggering factor was emotional stress (47%) in our study population. Ten patients (58.8%) had a classical form of TC, with apical left ventricular wall motion abnormalities. None of the patients died, and 15 (88.2%) had complete recovery of left ventricular systolic function. Only two patients (11.8%) had a left ventricular ejection fraction < 50% at the end of follow-up.Conclusion: This is the first retrospective data on childhood TC. The majority of patients with TC experienced an emotional stress as a trigger of the disease, and nearly 90% of the patients completely recovered.What is Known? • The occurrence of acute heart failure following an emotional or physical stress is called Takotsubo cardiomyopathy (TC). • Takotsubo cardiomyopathy is rarely reported in childrenWhat is New? • The present study is the first case series of children with TC. • In contrast to the female predominance in adult population, TC was almost equally distributed between boys and girls in the pediatric age group.

HEART BREAKS TO BREATHE: RECURRENT TAKOTSUBO CARDIOMYOPATHY IN COPD EXACERBATION

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Takotsubo syndrome (TTS) is defined as reversible stress-induced cardiomyopathy presenting as apical ballooning or mid-ventricular, basal, or focal wall motion abnormalities in the absence of coronary artery disease. It can be provoked by a stressful emotional situation or exposure to catecholamine surge. It’s a rare phenomenon to have a lung-heart axis leading to recurrent TTS. Here we present a rare case of recurrent TTS in the setting of COPD exacerbations also termed as bronchogenic TTS CASE PRESENTATION: 64 years old female with presented with dyspnea secondary to COPD exacerbation due to bacterial pneumonia was noted to have EKG changes with T-wave inversion, mild troponin elevation consistent with an ischemic lesion, elevated BNP 6103, followed by urgent cardiac catheterization noted to have non-significant coronary artery disease. Transthoracic echocardiogram (TTE) reported left ventricular ejection fraction (LVEF) of 25-29% with moderate sized apical, septal, posterior and anteroseptal wall motion abnormalities with akinesis of the segment consistent with TTS. Work up was negative for infective endocarditis, neurological and neuroendocrine tumor. She was treated with guideline-directed medical therapy (GDMT). LVEF normalized to 55%-59% in a follow up TTE. Seventeen months later she got readmitted with another episode of acute hypoxic hypercapnic respiratory failure requiring intubation with cardiac collapse. Patient had similar cardiac Catheterization findings but reduced LVEF of 30-34% consistent with TTS, again treated with GDMT, followed by a return of LVEF to normalization in a repeat TTE DISCUSSION: Recurrent TTS in the setting of COPD exacerbation is an extremely rare phenomenon exact cause of which remains unknown. Catecholamine surge causing microvascular dysfunction leading to cardiac stunning is a leading hypothesis. In COPD exacerbation adding beta 2 adrenergic agonists in management might potentiate worsening of cardiac stunning. Recurrent TTS has 19% overall risk for serious complications such as cardiogenic shock similar to acute coronary syndrome. The first step toward treatment is the removal of precipitating etiology like stress and in our case COPD exacerbation. ACE-inhibitors and angiotensin receptor blockers have a protective effect in reducing recurrent TTS while beta blockers have shown limited benefit. Even after recovery patient with TTS remains at high risk for electrical and mechanical complications CONCLUSIONS: Recurrent TTS in setting of COPD exacerbation has unknown incidence yet it highlights the intricate relationship of heart-lung axis. While TTS might be reversible, underlying pathophysiological insult might be permanent. We encourage physicians to not consider TTS as benign pathology and do every effort to reduce its recurrence. COPD exacerbation with TTS has worse prognosis with higher risk of hypoxic injury warranting improved COPD management. Reference #1: Rennyson, S. L., Parker, J. M., Symanski, J. D., & Littmann, L. (2010). Recurrent, severe, and rapidly reversible apical ballooning syndrome in status asthmaticus. Heart & Lung: The Journal of Acute and Critical Care, 39(6), 537-539. Reference #2: Manfredini, R., Fabbian, F., De Giorgi, A., Pala, M., Menegatti, A. M., Parisi, C., ... & Bossone, E. (2014). Heart and lung, a dangerous liaison-Tako-tsubo cardiomyopathy and respiratory diseases: a systematic review. World journal of cardiology, 6(5), 338. DISCLOSURES: No relevant relationships by Sreelatha Naik, source=Web Response No relevant relationships by Muhammad Pir, source=Web Response No relevant relationships by najam saqib, source=Web Response

Differentiating Takotsubo cardiomyopathy from ST-segment elevation myocardial infarction

Background: Takotsubo cardiomyopathy affects between 1.7% and 2.2% of patients hospitalized with suspected acute coronary syndromes. Characterized by chest pain, electrocardiogram changes, and transient left ventricular apical wall motion abnormality, it is under-recognized and often misdiagnosed. Objectives: In order to better differentiate between St-segment myocardial infarction and Takotsubo cardiomyopathy, we developed a scoring system. Methods: Of the 82 patients enrolled with Takotsubo cardiomyopathy, 67 had ST-segment elevation on electrocardiogram and were compared with 79 ST-elevation myocardial infarction patients. A multi-variant logistic regression model was used to find factors independently associated with Takotsubo cardiomyopathy. The Platelets and Thrombosis in Sheba (PLATIS)-Takotsubo cardiomyopathy is based on a 10-point scoring system: stressful events (3), females (2), no history of diabetes mellitus (2), estimated left ventricular ejection fraction ≤ 40% on admission echo (1), positive troponin on admission (1), and no smoking (1). Patients with Takotsubo cardiomyopathy were older (66 ± 11 vs 60 ± 11 years, p &lt; 0.001), predominantly female (90% vs 15%, p &lt; 0.001), with a lower incidence of diabetes mellitus, dyslipidemia, and smoking. Nevertheless, in-hospital mortality was similar in both groups. Results: In a multivariate logistic regression analysis, the average Platelets and Thrombosis in Sheba-Takotsubo cardiomyopathy scoring was significantly higher in Takotsubo cardiomyopathy compared with ST-elevation myocardial infarction patients (8.35 ± 1.7 vs 3.42 ± 1.6, p &lt; 0.001). With an overall score of ≥7, the receiver-operating characteristic curve was 0.82 with a sensitivity of 75% and a specificity of 89% (positive predictive value = 85% and negative predictive value = 80%). Conclusion: The Takotsubo cardiomyopathy scoring system is a simple, reliable tool that can assist in diagnosing and differentiating between patients with Takotsubo cardiomyopathy and those with ST-elevation myocardial infarction.

USE OF INTRAVASCULAR ULTRASOUND AND OPTIMAL COHERENCE TOMOGRAPHY FOR ETIOLOGICAL DIAGNOSIS IN A WOMAN PRESENTING WITH ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION, APICAL WALL MOTION ABNORMALITY AND NON-OBSTRUCTIVE CORONARY ARTERY DISEASE

The etiology of ST-segment Elevation Myocardial Infarction (STEMI) in non-obstructive coronary artery disease (CAD) and apical wall motion abnormality in women can be a diagnostic challenge. A 61-year-old woman with history of tobacco use presents with severe chest pain after exertion not resolved

Myocardial strain may be useful in differentiating Takotsubo cardiomyopathy from left anterior descending coronary artery ischemia

BackgroundStress-induced cardiomyopathy (SCM) is characterized by transient apical wall motion abnormalities of the left ventricle (LV) in the absence of obstructive coronary artery disease. Although the echocardiographic findings of SCM mimic those of left anterior descending coronary artery ischemia or infarction (LAD), the regional LV wall motion pattern and degree of RV involvement may differ. MethodsWe sought to systematically assess regional LV and RV function with myocardial strain imaging to assess if ventricular involvement may differ between SCM and LAD. ResultsThis was a retrospective cohort study, with 3 groups: patients with SCM (n=55), patients with LAD (n=36), and 37 normal subjects. All the patients had a comprehensive transthoracic echocardiographic examination, including assessment of longitudinal strain (LS). Global LV longitudinal strain was markedly decreased in both the SCM and LAD groups. However, SCM patients differed by more severe involvement the mid-inferolateral, mid-inferior, apical-lateral, and apical-inferior segments. When compared to the LAD patients, SCM patients had significantly more RV involvement both visually and quantitatively (27–42% versus 0–25%). Predictors of SCM included visually reduced RV systolic function, abnormal TAPSE, RVS′ and RV LS in the apical segment. Of the LV variables, regional LS in the mid-inferior and apical-inferior segments could differentiate the groups. ConclusionsOur results suggest that RV involvement and the pattern of LV regional LS abnormalities may help differentiate SCM from LAD disease during echocardiographic imaging.

Clinical and echocardiographic course in tako­tsubo cardiomyopathy: Long­term follow­up from a multicenter study

ObjectivesTo jointly describe clinical characteristics, ECG and echocardiographic findings, and adverse cardiovascular events in patients with tako-tsubo cardiomyopathy (TC) in the long-term. MethodsLongitudinal multicenter study including retrospective analysis of clinical and ECG data, and follow-up evaluation with clinical interview, electrocardiogram and echocardiogram. ResultsData from 66 cases of TC were available for analysis of clinical and adverse cardiovascular events, and 56 of them completed the follow-up visit including electrocardiogram and echocardiogram. Most patients (97%) were asymptomatic or oligosymptomatic (NYHA I [58%] or II [39%], respectively) at follow-up (median time: 3.7 [1.8–6.6] years). The vast majority of individual QRS complex and repolarization abnormalities had disappeared (87% with no ECG abnormalities at follow-up). On echocardiography, left ventricular ejection fraction was ≥50% in all patients (mean: 63±6%). Wall motion abnormalities were observed in 4 patients (7%; 3 with apical wall motion abnormalities and 1 with mild global hypokinesia). Long-term outcomes were as follows: 4 deaths (6%), 2 cardiovascular and 2 non-cardiovascular; no atrial fibrillation development; no stroke events; 5 acute recurrence events of TC (8%). Globally, 57 patients (86%) had a clinical course free from adverse cardiovascular events. ConclusionsAfter a long period following the admission event, patients discharged from TC remain asymptomatic or minimally symptomatic, and feature a low prevalence of both ECG and left ventricular wall motion abnormalities; moreover, the latter lead to a very mild impairment of ejection fraction. Among cardiovascular adverse events, recurrence of the TC event appears to play the most significant role.

Epidemiology of Tako-tsubo cardiomyopathy: the Tuscany Registry for Tako-tsubo Cardiomyopathy

Tako-tsubo (stress) cardiomyopathy (TTC) is a recently described acute cardiac syndrome that mimics ST-segment elevation myocardial infarction. The TTC Tuscany Registry is an observational prospective multicenter registry established to define the prevalence, epidemiology and prognosis of TTC in the Tuscany area. From January 1 to December 31, 2009, 105 consecutive patients hospitalized in the 14 Cardiology Units of the Tuscany Region with a diagnosis of TTC, were enrolled in the registry. TTC diagnosis was made using the Mayo Clinic modified criteria. Clinical, instrumental, laboratory and 6-month follow-up data were collected. Results. TTC represented 1.2% of all myocardial infarctions in the Tuscany Region during 2009, and it was diagnosed in 0.6% of the angiographic exams performed during the same year. The data collected showed that TTC affects mainly the female gender (91%) in the post-menopausal period (70 ± 11 years), though 5% of patients were ≤50 years old. An antecedent stressful event was frequently detected (74%). The main clinical presentation was chest pain (86%), associated with ST-segment elevation (59%). Mean left ventricular ejection fraction on admission was 40 ± 9%, and was associated with apical (37%), midapical (49%) or midventricular (5%) wall motion abnormalities. Left ventricular ejection fraction recovered to 51 ± 9% in 7 ± 9 days. Heart failure was the most common complication in the acute phase (14%), and 4 patients presented with cardiogenic shock. No patient died during the index hospitalization. At 6-month follow-up, no patient had TTC recurrence, 9 patients were rehospitalized (7 for noncardiac disease) and 2 patients died of noncardiac causes. Our data, which represent the largest prospective series of patients with a diagnosis of TTC, show that the prevalence of TTC in Tuscany is similar that described in other national and international studies. Moreover, the data highlight that TTC may occur also in male patients and in patients aged <50 years. The mid-term prognosis is good, but the risk of acute complications related to heart failure cannot be neglected.

Characteristics and mid-term follow-up of a single-center population affected by Tako-Tsubo cardiomyopathy.

Tako-Tsubo cardiomyopathy (TTC) is an acute cardiomyopathy mimicking acute myocardial infarction. The aim of our study was to define clinical and instrumental features of an Italian population of patients with TTC and to report their short and mid-term outcome. We retrospectively evaluated 42 patients admitted to our Department with diagnosis of TTC (100% women, age 67 ± 11 years) using Mayo Clinic-modified criteria. In this population, we analyzed the stressful event (if present), the clinical presentation, the ECG and echocardiogram at admission and the markers of myocardial cytonecrosis, such as troponin I, at admission and during the hospitalization. All the patients have been clinically evaluated after 6 months and 1 year of follow-up. In this population, a stressful event before TTC has been detected in 59% of patients. The most common clinical presentation was chest pain (81%) and the major sign was dyspnea (17%). ECG showed negative T waves and ST elevation, respectively, in 45 and 38%. Only 10% had a ST depression and 7% developed a newly acquired complete left bundle branch block. All of these abnormalities disappeared within 1.8 ± 0.9 days. The mean ejection fraction at admission was 35 ± 7% associated with apical (40%), mid-apical (56%) and mid-ventricular (4%) wall motion abnormalities. The recovery of these abnormalities occurred within 10 ± 3 days. At 6-month and 1-year follow-up, no patients had TTC recurrence, and 10 patients at 6 months and 20 patients at 1 year were re-hospitalized for a non-cardiac cause. Our data describe the characteristics of TTC in a small Italian population, which are similarly described in Japanese and North American people. TTC was related to a very low mortality, both in the short and mid term, but the risk of acute heart failure in the acute phase could not be neglected.