Inverted Takotsubo Cardiomyopathy Research Articles

FRI194 Pheochromocytoma Presenting As Catecholamine-Induced Cardiomyopathy: A Case Report

Abstract Disclosure: M. Tsikala Vafea: None. D. Lee: None. Introduction: Pheochromocytoma (PCC) is a rare catecholamine-secreting neuroendocrine tumor presenting with the classic triad of episodic headache, sweating and tachycardia. Catecholamine-induced cardiomyopathy (CICMP) can occur as a complication of PCC in 7-11% of patients. It presents more commonly as dilated cardiomyopathy and inverted Takotsubo cardiomyopathy but also as hypertrophic or unspecified cardiomyopathy. Following appropriate pharmacologic treatment and resection of PCC, these cardiac complications usually resolve. Case report: 36 year old man with history of hypertension presented to the hospital with worsening orthopnea and cough. Following antibiotic treatment failure for suspected pneumonia, he was re-admitted with hemoptysis, tachycardia, hypoxia, and hypertensive emergency. Troponin and brain natriuretic peptide were found to be elevated. CT chest and abdomen showed pulmonary nodules and a large left adrenal mass measuring 9.6x9.3x9.4 cm, concerning for metastatic PCC. He was subsequently started on doxazosin. Transthoracic echo showed bi-atrial enlargement, diffuse severe left ventricle hypokinesis, reduced ejection fraction 25% and diastolic dysfunction. Stress cardiac MRI showed non-ischemic cardiomyopathy, corroborating the diagnosis of CICMP. After achieving adequate alpha-adrenergic blockade, he was started on goal-direct medical therapy consisting of valsartan, metoprolol and empagliflozin. His pulmonary nodular opacities improved on repeat imaging, congruent with pulmonary edema rather than metastases. Plasma and 24-hour urine metanephrines (2,964 pg/mL and 23,310 mcg/24 hr, respectively) and normetanephrines (9,266 pg/mL and 33,927 mcg/24 hr, respectively), as well as dopamine (493 pg/mL), epinephrine (3,205 pg/mL) and norepinephrine (above reportable range of 4,800 pg/mL) eventually came back significantly elevated, confirming his diagnosis of PCC. A month after presentation, he underwent left adrenalectomy, which revealed an 11 cm composite PCC ganglioneuroma. One-month postoperatively, urine metanephrines and normetanephrines were normal but his ejection fraction remained unchanged. Discussion: CICMP should be considered in patients presenting with acute heart failure and an incidental adrenal mass to avoid delays in treatment. Acute pulmonary edema may resemble pulmonary nodules on CT, so interpretation of these findings should correlate with the clinical presentation. Timely initiation of alpha-adrenergic blockade upon suspicion of PCC is crucial as it can significantly improve hemodynamics, and biochemical markers take time to result. 96% of CICMP cases improve after resection of PCC within a variable time frame ranging from one week to several months. Our patient’s CICMP had not improved one month after his adrenalectomy, but it remains to be seen whether he eventually recovers his cardiac function. Presentation: Friday, June 16, 2023

Cardiac Arrest and Inverted Takotsubo Cardiomyopathy Following Intramyometrial Vasopressin Injection During Myomectomy.

Local vasopressin administration during gynaecological procedures can result in rare but severe cardiovascular compromise.Takotsubo cardiomyopathy can result from multiple rare causes.High-dose vasopressin may cause Takotsubo cardiomyopathy features via coronary vasoconstriction.

INVERTED TAKOTSUBO CARDIOMYOPATHY FOLLOWING BRAIN HEMATOMA

Inverted takotsubo is an entity that until now overlooked by healthcare practitioners.Its appearance in severe neurological disorders makes him a subject of exciting research. In this article, we report the case of a women 37 years old presenting with during a comitial attack associated 2 hours later with chest pain mimicking acute coronary syndrome.Echocardiography revealed an extensive left ventricular akinesis except at the apex. Coronary angiography performed hasshowen healthy coronary arteries. Cardiac magnetic resonance imaging (MRI) analysis confirms the diagnosis of inverted takotsubo cardiomyopathy.

Inverted Takotsubo cardiomyopathy in a surgical patient with Crohn’s disease flare

Stress-induced, or Takotsubo, cardiomyopathy, is a relatively uncommon cause of left ventricular (LV) dysfunction that can mimic myocardial ischemia. This report presents a case of inverted Takotsubo cardiomyopathy associated with severe electrolyte imbalance in the setting of a Crohn’s disease flare. Bedside echocardiography can be a useful tool to establish a prompt diagnosis.

Transthoracic echocardiography consistent with inverted Takotsubo cardiomyopathy with estimated left ventricular ejection fraction of 15–20%

Transthoracic echocardiography consistent with inverted Takotsubo cardiomyopathy with estimated left ventricular ejection fraction of 15–20%

(55) Inverted Takotsubo Cardiomyopathy leading to Cardiac Arrest, rescued by ECMO (E-CPR) in a Pediatric Patient with Traumatic Subarachnoid Hemorrhage

(55) Inverted Takotsubo Cardiomyopathy leading to Cardiac Arrest, rescued by ECMO (E-CPR) in a Pediatric Patient with Traumatic Subarachnoid Hemorrhage

Pheochromocytoma as a reversible cause of cardiomyopathy: Analysis and review of the literature

ContextPheochromocytoma and paraganglioma are rare neuroendocrine tumors which overproduce catecholamines and arise from the adrenal gland or extra-adrenal chromaffin cells of the sympathetic and parasympathetic ganglia (1). Excessive catecholamine-induced stimulation of cardiac myocytes leads to damage which manifests in several forms ranging from Takotsubo to dilated cardiomyopathy. Diagnosis of pheochromocytoma-related cardiomyopathies is often delayed due to the atypical presentation associated with many cases. ObjectiveLimited data exists on the presentation and outcomes of the various forms of pheochromocytoma-induced cardiomyopathies. We performed a literature review to assess the association of pheochromocytoma and cardiomyopathy to aide in further understanding this clinical entity. Design163 cases from 150 articles published between 1991 and November 2016 were included from a PubMed search. ResultsThere were 163 occurrences of pheochromocytoma and cardiomyopathy (63 dilated cardiomyopathy, 38 Takotsubo cardiomyopathy, 30 inverted Takotsubo cardiomyopathy, 10 HOCM, 8 myocarditis, and 14 unspecified cardiomyopathy). Many patients lacked classic signs or symptoms of pheochromocytoma with hypertension as a presenting symptom in 65% and the triad of headache, palpitations, and diaphoresis only in 4%. Resection of the pheochromocytoma led to improvement of the cardiomyopathy in 96% while lack of resection was associated with death or cardiac transplantation in 44%. ConclusionPheochromocytoma should be considered in the evaluation of non-ischemic, non-valvular cardiomyopathy even in the absence of symptoms of catecholamine excess. Our study highlights the importance of early suspicion and diagnosis of pheochromocytoma in cases of idiopathic heart failure as early resection may prevent progression to irreversible myocardial remodeling and death.

Heart Failure in a Case of Inverted Takotsubo Cardiomyopathy due to Cocaine and Methamphetamine Abuse Treated with Levosimendan

Heart Failure in a Case of Inverted Takotsubo Cardiomyopathy due to Cocaine and Methamphetamine Abuse Treated with Levosimendan

Successful treatment of inverted Takotsubo cardiomyopathy after severe traumatic brain injury with milrinone after dobutamine failure

BackgroundTakotsubo cardiomyopathy can occur at the early phase of severe acute brain injuries. In the case of cardiac output decrease or shock, the optimal treatment is still a matter of debate. Due to massive stress hormone release, the infusion of catecholamines may have limited effects and may even aggravate cardiac failure. Other inotropic agents may be an option. Levosimendan has been shown to have potential beneficial effects in this setting, although milrinone has not been studied. MethodsWe report a case of a young female presenting with inverted Takotsubo cardiomyopathy syndrome after severe traumatic brain injury. ResultsDue to hemodynamic instability and increasing levels of infused norepinephrine, dobutamine infusion was begun but rapidly stopped due to tachyarrhythmia. Milrinone infusion stabilized the patient's hemodynamic status and improved cardiac output without deleterious effects. ConclusionMilrinone could be a good alternative when inotropes are required in Takotsubo cardiomyopathy and when dobutamine infusion is associated with tachyarrhythmia.

Dual Diagnostic Role of 123I-MIBG Scintigraphy in Inverted Takotsubo Cardiomyopathy: Reply.

Dual Diagnostic Role of 123I-MIBG Scintigraphy in Inverted Takotsubo Cardiomyopathy: Reply.

Cardiogenic Shock due to Psychosis-Induced Inverted Takotsubo Cardiomyopathy Bridged-to-Recovery with a Percutaneous Left Ventricular Assist Device.

Inverted Takotsubo cardiomyopathy, a less common variant in the spectrum of stress-induced cardiomyopathy, is increasingly being reported. This report describes an acute psychiatric illness leading to the onset of this syndrome. The patient presented here developed cardiogenic shock but successfully recovered with the use of a percutaneous left ventricular assist device.

Inverted Takotsubo cardiomyopathy after attempted suicidal hanging – Two cases

We report two cases of “Inverted Takotsubo cardiomyopathy” following attempted suicidal hanging. Both the patients presented with heart failure and had desaturation 8–12h after the suicidal attempt. Electrocardiography (ECG) showed ischemic changes. On echocardiography, the left ventricle (LV) showed ballooning and hypokinesia of the basal segments with apical sparing. Both patients underwent coronary angiograms considering the possibility of acute coronary syndrome. However, their coronary angiograms were normal. After 3–4 days of hospitalization, both recovered; their ECG had reversed and the LV contractility was normal on echocardiography.

Pheochromocytoma presenting as inverted Takotsubo cardiomyopathy

The classical entity of Takotsubo cardiomyopathy is well established in the literature, but mechanisms explaining it remain unelucidated. Recently, the uncommon inverted Takotsubo type (sparing apical ballooning) has been more frequently described. We report the case of a 26-year-old man admitted with gastrointestinal symptoms, whose clinical presentation for a stress-related cardiomyopathy, which usually presents with cardiopulmonary symptoms, was rather atypical. The cardiac assessment including echocardiography and cardiac magnetic resonance imaging (MRI) demonstrated a dilated cardiomyopathy, whereas coronary angiography showed the absence of atherosclerotic disease. The abdominal computed tomography (CT) scan revealed a left adrenal mass, and elevated urinary catecholamine levels were highly suggestive of a pheochromocytoma. Prompt medical and surgical treatments were instituted. During the left adrenalectomy the patient suffered from brief electromechanical dissociation requiring aggressive resuscitation. Postoperative course was unremarkable. Reverse Takotsubo heart failure is a recently recognized syndrome and a systematic review of the literature of 10 cases of pheochromocytoma-induced inverted Takotsubo is presented in the present article.

Inverted takotsubo cardiomyopathy in a patient with right adrenal massive hemorrhage

Inverted takotsubo cardiomyopathy in a patient with right adrenal massive hemorrhage

Inverted-Takotsubo cardiomyopathy: severe refractory heart failure in poly-trauma patients saved by emergency extracorporeal life support.

The sequelae of severe poly-trauma may include myocardial dysfunction followed by acute heart failure and death. Inverted-Takotsubo cardiomyopathy (ITC) is a variant of stress cardiomyopathy, characterized by a contractile abnormality with extensive left ventricular circumferential dyskinesia or akinesia with a hyperkinetic apex. We report our experience with refractory cardiogenic shock and/or cardiac arrest, treated with extracorporeal life support. From June 2008 to December 2011, we treated 4 adult poly-trauma patients (3 men, 1 woman, mean age: 27.7 ± 13.5 years, mean ISS score 53.2 ± 15.9) with veno-arterial (V-A) extracorporeal life support for cardiopulmonary failure/cardiac arrest refractory to conventional treatment, due to inverted-Takotsubo cardiomyopathy. We used a miniaturized extracorporeal life support (ECLS) device. ITC myocardial dysfunction appeared 15.4 ± 11.6 h after intensive care unit admission and rapidly evolved to refractory cardiopulmonary failure and cardiac arrest (within 4.8 ± 2.5 h of the onset). At ECLS, initiation median pH was 7.12 ± 0.14 (6.91-7.25), median lactate was 6.7 ± 2.8 (4-10) mmol/l and median vasoactive-inotropic score was 192.1 ± 50.6 µg/kg/min. Tissue perfusion improved significantly within 4 h on ECLS. Cardiac function improved gradually but consistently. Initial median ejection fraction was 14.2 ± 4.7% and median global longitudinal strain test was -7.4 ± 4.7. At complete cardiac recovery, they were 62.73 ± 7.8 and -18.43 ± 2.4%, respectively. After that, 2 patients survived and were sent to neurological rehabilitation before hospital discharge. In the other 2 cases, post-traumatic cerebral death occurred and they underwent organ explantation. Rapid heparin-free ECLS may improve outcome in the most severe cases of poly-traumatized patients demonstrating refractory inverted-Takotsubo cardiomyopathy.

Association of inverted Takotsubo cardiomyopathy with postpartum pneumo-mediastinum: when a “broken lung” meets a “broken heart”

Association of inverted Takotsubo cardiomyopathy with postpartum pneumo-mediastinum 1 1 3 Six hours after an uneventful delivery, a 30-year-old primiparous woman complained of pleuritic-type chest pain and sense of immense apprehension. Initially, Troponin-I (Tn-I) level was normal (0.01 ng/mL), but D-dimer was elevated (1200 μg/L). Pulmonary embolism was excluded by a computed tomography scan, which revealed signs of pneumo-mediastinum and subcutaneous emphysema (a). Shortly after, due to raised Tn-I level to 1.88 ng/mL and T-wave inversion in anterior precordial leads, she was referred to us. Angiography disclosed normal coronary arteries (b, c), but wall-motion abnormalities (WMA) in basal segments were noted (d). Cardiac magnetic resonance imaging excluded late gadolinium enhancement (e, f ). Transthoracic echocardiography showed significant hypoto akinesis of basal inferior and posterior left ventricular wall and dyskinesis of basal anteroseptal segments (g, h). Estimated ejection fraction (EF) by 3D quantification was 27 % (i, j). This peculiar pattern of WMA with clinical settings and normal coronary arteries was consistent with reversed/ inverted Takotsubo cardiomyopathy (ITC). She received appropriate management with beta-blockers and angiotensin-converting enzyme inhibitors. EF was completely normalized after 1 month (k, l). To the best of our knowledge, this association of pneumo-mediastinum and ITC has not been reported. Notably, ITC occurs more frequently in younger age and is more commonly associated with mental stress than the typical forms of Takotsubo cardiomyopathy.

Inverted Takotsubo Cardiomyopathy—Clinicopathologic Correlation

We report the case of a 34-year-old woman who presented after a witnessed out-of-hospital arrest. Initial cardiac rhythm at the time of resuscitation was ventricular fibrillation. Subsequently in hospital, she developed further episodes of polymorphic ventricular tachycardia and ventricular fibrillation. Urgent echocardiography showed features suggestive of an inverted takotsubo cardiomyopathy. Twenty-four hours after admission, there was a further episode of polymorphic ventricular tachycardia from which the patient could not be resuscitated. An autopsy confirmed the cause of death as inverted takotsubo cardiomyopathy. We present the pathological findings from the postmortem autopsy.

The diagnostic challenge of acute heart failure: the heart interacting with systemic organs

We present a clinical case of a 56-year-old woman with medical history of obesity and asthma treated with bronchodilators and inhaled corticosteroids. Because of a severe bronchospasm episode she initiated oral corticosteroid and 48 hours later she started epigastric discomfort, vomiting, diaphoresis and palpitations. She presented to our emergency department with hypertension (190/100 mmHg) and tachycardia (130 beats per minute). Electrocardiogram identified sinus tachycardia with anterolateral ST segment depression. Cardiac biomarkers were elevated (peak troponin I of 11.2 ng/mL) and chest radiograph was normal. Transthoracic echocardiogram revealed mild left ventricular (LV) systolic dysfunction with inferior hypokinesia. She was transferred to our coronary care unit with the diagnosis of non-ST elevation myocardial infarction. Coronary angiography demonstrated absence of obstructive coronary disease. Patient developed acute heart failure and progressive pulmonary congestion. She also manifested recurrent episodes of vomiting and palpitations associated with sinus tachycardia (120-160 bpm), cyclic hypertensive crisis (blood pressure of 210/120 mmHg) alternating with hypotension as well as hyperthermia. Laboratory values revealed elevated leukocyte count and C-reactive protein values which led to consider as the most probable the diagnosis of acute myocarditis. Echocardiography reevaluation showed severe LV dysfunction with basal segments akinesia and apex hypercontractility suggesting the pattern of inverted Takotsubo cardiomyopathy. Patient was subsequently referred for a cardiac magnetic resonance study to further evaluate LV function and myocardial tissue characterization. LV cine images revealed total systolic function recuperation, T2-weigthed imaging without edema and absence of late gadolinium enhancement. In addition, a large masse was identified in the right suprarenal gland, suggesting pheochromocytoma. Serum catecholamines were increased and functional imaging by I-123 labeled meta-iodobenzylguanide scan demonstrated abnormal uptake in the right adrenal only. Patient underwent surgical resection of the adrenal mass and histology confirmed the diagnosis of secreting pheochromocytoma. Patient was then discharged asymptomatic. Although rare, pheochromocytoma should be considered in the differential diagnosis of Takotsubo-like cardiomyopathy and systemic glucocorticoids should also be considered as a probable trigger for serum catecholamine release in those patients.

Post-Procedural Inverted Takotsubo Cardiomyopathy

A year old-woman with rheumatoid arthritis was admitted to the hospital for evaluation of dyspnoea. CT scan of the chest revealed bilateral pulmonary nodules. Shortly after bronchoscopy with transbronchial biopsy, she developed anxiety, diaphoresis, dyspnoea, and tachycardia. Initial troponin T was elevated. Due to concern for procedural myocardial infarction (MI), aspirin, improvement in LV basal function, consistent with the diagnosis of inverted Takotsubo cardiomyopathy.

Inverted-Takotsubo Cardiomyopathy in a Patient with Pulmonary Embolism

As the use of early coronary angiography and echocardiography become widely available in the setting of acute coronary syndrome, the gradual increase for variant forms of transient left ventricular (LV) apical ballooning syndrome have been recognized. This syndrome usually occurs in women and is frequently elicited by an intense emotional, psychological, and physical event. While the patients' characteristics between typical and non-typical LV ballooning syndrome seem to differ, the presentation, clinical features, and reversibility of LV wall motion abnormalities are similar. We present a middle-aged woman who experienced inverted takotsubo cardiomyopathy triggered by pulmonary embolism. To the best of our knowledge, this case is particularly unique and is rarely reported in the disease entity.