Midventricular Ballooning Research Articles

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.

Encasement of the left anterior descending coronary artery: association with Takotsubo syndrome, and diagnostic and therapeutic options

Myocardial bridging is a rare event, which leads to chest pain, arrhythmias and discussable Takotsubo syndrome (cardiomyopathy). We enrolled 41 patients (33 females, mean age 68.4 years), the majority of whom had Takotsubo cardiomyopathy in any form, and 6 had echocardiographic midventricular hypokinesia along with chest pain. Thirty patients had apical ballooning, 3 had midventricular ballooning, and 1 had basal ballooning, according to left ventricular angiography. Intravascular ultrasonography and fractional flow reserve with either an adenosine or dobutamine injection are the best methods for accurately diagnosing myocardial bridging. Beyond atherosclerosis, myocardial bridging is a prominent cause of chest pain, although ischemia is difficult to verify.

Encasement of the left anterior descending coronary artery: association with Takotsubo syndrome, and diagnostic and therapeutic options

Myocardial bridging is a rare event, which leads to chest pain, arrhythmias and discussable Takotsubo syndrome (cardiomyopathy). We enrolled 41 patients (33 females, mean age 68.4 years), the majority of whom had Takotsubo cardiomyopathy in any form, and 6 had echocardiographic midventricular hypokinesia along with chest pain. Thirty patients had apical ballooning, 3 had midventricular ballooning, and 1 had basal ballooning, according to left ventricular angiography. Intravascular ultrasonography and fractional flow reserve with either an adenosine or dobutamine injection are the best methods for accurately diagnosing myocardial bridging. Beyond atherosclerosis, myocardial bridging is a prominent cause of chest pain, although ischemia is difficult to verify.

Encasement of the left anterior descending coronary artery: association with Takotsubo syndrome, and diagnostic and therapeutic options

Myocardial bridging is a rare event, which leads to chest pain, arrhythmias and discussable Takotsubo syndrome (cardiomyopathy). We enrolled 41 patients (33 females, mean age 68.4 years), the majority of whom had Takotsubo cardiomyopathy in any form, and 6 had echocardiographic midventricular hypokinesia along with chest pain. Thirty patients had apical ballooning, 3 had midventricular ballooning, and 1 had basal ballooning, according to left ventricular angiography. Intravascular ultrasonography and fractional flow reserve with either an adenosine or dobutamine injection are the best methods for accurately diagnosing myocardial bridging. Beyond atherosclerosis, myocardial bridging is a prominent cause of chest pain, although ischemia is difficult to verify.

A changing heart in tako-tsubo syndrome.

A 63-year-old female presented with acute chest pain and ECG showing T wave inversion in the anterior and inferior leads. Troponin T (TnT) was significantly elevated (peak 1378 ng/L; normal <14 ng/L), as was NT-proBNP (3091 ng/L; normal <400 ng/L). Invasive angiography showed unobstructed coronary arteries with mid-ventricular ballooning and hypokinesia on ventriculography (see Supplementary data online, Video S1) and echocardiography (see Supplementary data online, Video S2), suggesting a mid-ventricular tako-tsubo syndrome (TTS). Cardiac magnetic resonance (CMR) was booked but the patient was unable to attend. Focussed history using the InterTAK diagnostic score assessment revealed no emotional or physical triggers. The patient re-presented six months later with similar symptoms and elevated TnT. Inpatient echocardiography showed a reverse TTS pattern (see Supplementary data online, Video S3) and CMR at 1.5T showed basal hypokinesia with matching elevated native T1 (1220 ms; normal 950–1100 ms) and T2 (69 ms; normal <48 ms) (Panels A–B). Quantitative perfusion maps following adenosine stress perfusion to investigate microvascular disease showed basal to mid circumferential hypoperfusion with normal apical myocardial blood flow, not suggestive of specific coronary artery territory ischaemia (Panel D) and no late gadolinium enhancement (LGE) (Panel C), confirming a reverse TTS. The patient further presented two months later with chest pain and TnT elevation. Repeat inpatient CMR on this occasion showed a classic TTS pattern with apical hypokinesia and elevated T1 and T2 (1261 ms and 81 ms, respectively) at the mid to apical segments with no LGE (Panels E–G). The case was further explored but no triggers, including neurological or psychiatric abnormalities were found. Recurrent TTS with different phenotypes has previously been described but is rare, especially without a trigger. Our case illustrates the utility of multimodality imaging in the investigation of TTS; in particular, multiparametric tissue mapping by CMR. Furthermore, the novel quantitative perfusion maps characterising myocardial blood flow added diagnostic utility.

Neutrophile-lymphocyte ratio and outcome in takotsubo syndrome

Abstract Introduction Takotsubo syndrome (TTS) is an important form of acute heart failure with significant risk of acute complications and death. In this analysis we sought to identify predictors for in-hospital clinical outcome in TTS patients by concentrating on routine laboratory parameters at admission. Methods In this analysis from the Austrian national TTS registry, univariable and multivariable analyses were performed to identify significant predictors for severe in-hospital complications requiring immediate invasive treatment or leading to irreversible damage, such as cardiogenic shock, intubation, stroke, arrhythmias and death. Furthermore, the influence of identified predictors with long-term survival was evaluated. Results A total of 338 patients (median age 72 years, 86.9% female) from 6 centres were included. Severe in-hospital complications occurred in 14.5% of patients, including cardiogenic shock (9.8%), death (3.3%) and intubation (1.2%), respectively. Patients with complications during the hospital stay had more prevalent chronic kidney disease (CKD), were less often previous smokers and TTS was less often preceded by an emotional trigger. C-reactive protein and neutrophile lymphocyte ratio (NLR) was higher in patients with complications, and midventricular ballooning and reduced left ventricular ejection fraction (LVEF) were more prevalent. In multivariable analysis, high NLR (OR 1.04 [95% CI 1.02–1.07], p=0.009) and low LVEF (OR 0.92 [0.90–0.95] per %, p&amp;lt;0.001) remained significant predictors for severe in-hospital complications. Both the highest NLR tercile and the lowest LVEF tercile were associated with significantly reduced 5-year survival. Discussion Low LVEF and high NLR at admission were independently associated with increased in-hospital complications and reduced long-term survival in TTS patients. NLR is a new easy-to-measure tool to predict worse short and long-term outcome after TTS. Funding Acknowledgement Type of funding sources: None.

Happy Heart Syndrome: Frequency, Characteristics, and Outcome of Takotsubo Syndrome Triggered by Positive Life Events

BackgroundThe association with a preceding stressor is a characteristic feature of takotsubo syndrome (TTS). Negative emotions before TTS are common and led to the popular term “broken heart syndrome.” In contrast, pleasant triggers (“happy heart syndrome”) are rare and are scarcely investigated. ObjectivesThe authors analyzed the frequency, clinical characteristics, and prognostic implications of positive emotional stressors in the multicenter GEIST (GErman-Italian-Spanish Takotsubo) Registry. MethodsPatients enrolled in the registry were categorized according to their stressors. This analysis compared patients with pleasant emotional events with patients with negative emotional events. ResultsOf 2,482 patients in the registry, 910 patients (36.7%) exhibited an emotional trigger consisting of 873 “broken hearts” (95.9%) and 37 “happy hearts” (4.1%). Consequently, the prevalence of pleasant emotional triggers was 1.5% of all TTS cases. Compared with patients with TTS with negative preceding events, patients with happy heart syndrome were more frequently male (18.9% vs 5.0%; P < 0.01) and had a higher prevalence of atypical ballooning patterns (27.0% vs 12.5%; P = 0.01), particularly midventricular ballooning. In-hospital complications, including death, pulmonary edema, cardiogenic shock, or stroke (8.1% vs 12.3%; P = 0.45), and long-term mortality rates (2.7% vs 8.8%; P = 0.20) were similar in “happy hearts” and “broken hearts.” ConclusionsHappy heart syndrome is a rare type of TTS characterized by a higher prevalence of male patients and atypical, nonapical ballooning compared with patients with negative emotional stressors. Despite similar short- and long-term outcomes in our study, additional data are needed to explore whether numerically lower event rates in “happy hearts” would be statistically significant in a larger sample size. (GErman-Italian-Spanish Takotsubo Registry [GEIST Registry]; NCT04361994)

Left Ventricular Ballooning Patterns in Recurrent Takotsubo Cardiomyopathy: A Systematic Review and Meta-analysis of Reported Cases.

Recurrent takotsubo cardiomyopathy (TTC) and the clinical profiles and outcomes of patients have not been fully evaluated, nor has the effect of left ventricular ballooning pattern. After searching the medical literature for reports of patients with recurrent TTC, we identified 84 articles with 101 case descriptions. We divided the cases into those with only apical left ventricular ballooning patterns at recurrence (typical, n=60), and those with at least one midventricular or basal ballooning pattern (atypical, n=41). We then compared their clinical profiles and outcomes. The groups were similar in terms of baseline demographic characteristics, presence and types of triggers, use of heart failure medications at TTC recurrence, electrocardiographic changes at presentation, initial left ventricular ejection fractions, timespans between recurrent TTC episodes, and recovery times after each event. However, patients in the atypical group had significantly fewer severe adverse events (cardiogenic shock and cardiac arrest) than did those in the typical group, with an estimated 63% lower odds (adjusted odds ratio=0.37; 95% CI, 0.14-0.97; P=0.039). Survival to hospital discharge was statistically similar but lower in the typical group (n=53; 88.3%) than in the atypical group (n=24; 96%). Our results suggest that left ventricular ballooning patterns influence clinical outcomes, and that outcomes are more favorable in patients with recurrent TTC who have atypical left ventricular ballooning patterns.

Left ventricular mechanics in the acute phase of Takotsubo cardiomyopathy: distinctive ballooning patterns translate into different diastolic properties.

Although apical and midventricular Takotsubo cardiomyopathies (TTCs) share common triggers and pathophysiological features, little is known about the potential differences in left ventricular (LV) mechanistic properties between these TTC phenotypes. We sought to investigate whether LV systolic and/or diastolic function, as assessed invasively by left heart catheterization (LHC), differ according to ballooning patterns in the acute phase of TTC. One hundred and fourteen TTC patients were retrospectively identified between January 2009 and December 2015 at the University Hospital of Strasbourg, France. A comprehensive list of LV quantitative parameters was derived from LHC analysis for each patient. We examined 2 groups of patients according to ballooning patterns in the acute phase of TTC: patients with apical ballooning ("Apical group"; n = 76) and those with midventricular ballooning ("Midventricular group"; n = 38). LV minimal diastolic pressure (8.72 ± 6.72 vs. 5.02 ± 6.08mmHg; p = 0.004), LV end diastolic pressure (23.11 ± 8.32 vs. 18.84 ± 8.06mmHg; p = 0.01), and LV diastolic stiffness (LV stiffness 1: 0.29 ± 0.23 vs. 18.84 ± 8.06mmHg/mL; p = 0.04-LV stiffness 2: 0.16 ± 0.08 vs. 0.12 ± 0.05mmHg/mL; p = 0.005) were significantly higher in patients with apical TTC than in the midventricular group. Concomitantly, these findings were associated with significantly higher BNP levels in the apical group (923.91 ± 1164.53 vs. 418.71 ± 557.75pg/mL; p = 0.004) than in the midventricular group. In the acute phase of stress cardiomyopathy, the classic apical form of TTC is associated with poorer diastolic function compared to the midventricular ballooning variant, as assessed through direct invasive hemodynamic measurements using LHC.

Takotsubo syndrome in young fertile women

Background: Takotsubo syndrome (TTS) is an acute heart syndrome characterised by reversible ventricular dysfunction with the absence of significant coronary occlusion, which typically occurs in postmenopausal women after emotional or physical stress. Differences of clinical or instrumental characteristics between fertile women and postmenopausal women with TTS have not yet been studied. The aim of this study was to investigate the differences in clinical, biochemical and echocardiographic characteristics between postmenopausal women and fertile women with TTS.Methods: One hundred and thirty-one patients (mean age 67.8 ± 11.3 years; 14 patients were still fertile) from four different Italian hospitals were enrolled, partially retrospectively and partial longitudinally. Physical examination, clinical history (including presenting symptoms and triggering stress factors), laboratory and ECG findings and Doppler echocardiography were collected at hospital admission. Echocardiography was repeated at discharge (after at least seven days from admission).Results: No significant differences were observed considering trigger events or symptoms at presentation. Significant differences were observed considering left ventricle ejection fraction (LVEF) (37.9 ± 14.4% in fertile women, 43.9 ± 9.7% in postmenopausal women, p = .033) and regional wall motion abnormalities. The apical ballooning pattern was predominant in postmenopausal women, instead the midventricular type was mainly observed in fertile women (36% versus 1% in fertile versus postmenopausal women respectively, p < .001).Conclusions: Echocardiographic involvement of left ventricle is atypical in fertile women compared to women in menopause (midventricular versus apical ballooning, respectively). Moreover, the young group presented with worse LVEF but they had the same LV function at discharge and similar prognosis.

Encasement of the Left Anterior Descending Coronary Artery: Association with Takotsubo Syndrome, and Diagnostic and Therapeutic Options

Myocardial bridging is a rare event, which leads to chest pain, arrhythmias and discussable takotsubo syndrome (cardiomyopathy).We collected 41 patients (33 females, mean age 68.4 years) with all forms of takotsubo cardiomyopathy in most cases and 6 cases with chest pain and echocardiographic mid-ventricular hypokinesia. Left ventricular angiography revealed apical ballooning in 30 patients, mid-ventricular ballooning in 3 cases, and basal ballooning in one case.The correct diagnosis of myocardial bridging can be best made by intravascular ultrasound (IVUS) and fractional flow reserve (FFR) with either adenosine or dobutamine injection.Beyond atherosclerosis, myocardial bridging is a prominent cause of chest pain, although ischemia is difficult to verify.

Happy heart syndrome

A 62-year-old woman with a history of hypertension was brought to the emergency department presenting with acute chest pain for 3 hours. An immediate electrocardiogram showed ST-segment elevation in the...

Left ventricular myocardial deformation in Takotsubo syndrome: a cardiovascular magnetic resonance myocardial feature tracking study.

This study assessed the applicability and prognostic value of cardiovascular magnetic resonance (CMR) left ventricular deformation analysis in Takotsubo syndrome (TTS). CMR-feature tracking was performed blinded in a core laboratory to determine circumferential (CS), radial (RS) and longitudinal strain (LS) in 141 TTS patients participating in this cohort study. A subgroup of consecutive TTS patients (n = 20) was compared with age- and sex-matched controls with anterior ST-segment elevation myocardial infarction (STEMI) and non-STEMI as well as healthy subjects. Median global CS, RS and LS were -19%, 19% and -12%, respectively. Apical ballooning was associated with significantly lower global CS (p < 0.01) and LS (p < 0.01) compared with midventricular and basal ballooning. Global RS was lowest in patients with basal ballooning (p < 0.01). Segmental analysis resulted in a reliable discrimination of different ballooning patterns using CS and LS. Strain values were significantly lower in TTS compared with non-STEMI patients and healthy subjects, whereas STEMI patients showed similar values. While global CS and RS were not associated with long-term mortality, global LS (cutoff -14.75%) was identified as a potential parameter for long-term risk stratification (mortality rate 17.9% versus 2.5%; p = 0.02). The transient contraction abnormalities in TTS can be quantitatively assessed with CMR-feature tracking. GLS is a potential determinant of outcome in TTS, which, however, requires further validation. • Cardiovascular magnetic resonance myocardial feature tracking enables accurate assessment of regional and global left ventricular dysfunction in Takotsubo syndrome (TTS). • Global strain in TTS is similar to patients with anterior STEMI and lower compared with non-STEMI and healthy subjects. • Global longitudinal strain is a potential tool for risk prediction in TTS patients.

Prognostic Usefulness of the Ballooning Pattern in Patients With Takotsubo Cardiomyopathy

The aim of the present analysis was to evaluate the prognostic impact of different ballooning patterns in patients with Takotsubo cardiomyopathy (TTC). A total of 285 consecutive patients with TTC were included. Clinical characteristics and short- and long-term outcomes were compared between patients with typical apical ballooning (n=204) and patients with an atypical ballooning pattern including midventricular and basal ballooning (n= 81). Patients with typical apical ballooning were significantly older (73.3 ± 10.2 vs 68.4 ± 10.3years; p <0.01) and had a higher prevalence of diabetes mellitus (25.5% vs 12.3%; p= 0.02). The initial left ventricular (LV) ejection fraction was significantly lower in case of apical ballooning (41.5 ± 10.4% vs 46.9 ± 10.9%; p <0.01) but recovered to normal values in both groups (58.4 ± 8.0 vs 59.7 ± 7.0; p= 0.25). Although 28-day mortality did not differ significantly (p= 0.10), typical apical ballooning was associated with an increased 6-month (13.4% vs 1.3%; hazard ratio [HR] 10.81, 95% confidence interval [CI] 1.47 to 79.66; p= 0.02) and long-term mortality rates (28.9% vs 14.5%; HR 2.24, 95% CI 1.17 to 4.71; p= 0.02). A landmark analysis which included only patients who survived the first 6months after the initial event demonstrated similar mortality rates in patients with typical (17.9%) and atypical (13.3%) ballooning (HR 1.36, 95% CI 0.67 to 2.79; p=0.40). In conclusion, in patients with TTC, typical apical ballooning is associated with more severe LV dysfunction at acute presentation and higher mortality rates within the first 6months after the initial event. After complete recovery of LV function, prognosis is similar in patients with typical and atypical ballooning patterns.

Mid-Ventricular Ballooning in Atherosclerotic and Non-Atherosclerotic Abnormalities of the Left Anterior Descending Coronary Artery

Mid-Ventricular Ballooning in Atherosclerotic and Non-Atherosclerotic Abnormalities of the Left Anterior Descending Coronary Artery

Abstract 17041: Impact of Different Patterns of Left Ventricular Ballooning in Patients With Stress (Takotsubo) Cardiomyopathy: Single Center Clinical Experience

Introduction: Stress cardiomyopathy (SCMP) is characterized by acute reversible left ventricular (LV) dysfunction, and it is well accepted that SCMP can show various patterns with or without apical involvement. However, clinical data describing characteristics and outcomes according to the patterns of LV ballooning are lacking. Methods: We retrospectively identified 549 consecutive patients (age, 64±15 years; 328 female) with SCMP in a single tertiary hospital from Jan 2009 to June 2014. They were divided into 2 groups with typical apical ballooning (group 1) and atypical patterns sparing the LV apical segment (group 2). Clinical characteristics and outcomes including in-hospital mortality were explored. Results: Apical ballooning was most common (n=394, 71.8%) and group 2 included mid-ventricular ballooning (21.7%), basal ‘inverted’ ballooning (2.9%), global hypokinesia (1.8%), localized ballooning (1.1%), and isolated right ventricular ballooning (0.7%). Group 1 was characterized by higher mean age (67±13 vs. 55±17 years, p&lt;0.001) with higher prevalence of coronary risk factors including obesity, hypertension, hyperlipidemia and diabetes mellitus. Emotional stress was a triggering event in a very limited patients comprising &lt; 5%, whereas physical stress associated with underlying medical conditions comprised more than 70%. Distribution of triggering events was similar between groups. ECG abnormalities including T wave inversion, ST segment elevation, QT prolongation and atrial fibrillation were more frequent in group 1 than group 2 with lower LV ejection fraction. However, in-hospital mortality was comparable between groups (24% vs. 21%, p=0.52). Conclusions: Apical sparing ballooning develops in up to 30% of patients with SCMP. Younger age, favorable medical conditions, less severe ECG changes, and higher LV ejection fraction cannot translate to lower mortality in this group. Physicians’ vigilance is needed to improve clinical outcomes.

ECG in patients with tako tsubo cardiomyopathy

Takotsubo cardiomyopathy, also known as transient left ventricular ballooning and stress myocardiopathy, has been diagnosed increasingly more over the last decade. The takotsubo syndrome mimics acute myocardial infarction in symptoms and in electrocardiographic findings. There are two major types of takotsubo cardiomyopathy: the classical type with left ventricular apical ballooning and a type with midventricular ballooning. Both types show different electrocardiographic patterns at presentation. The present article describes classical electrocardiographic findings of the acute and subacute phases of takotsubo cardiomyopathy.

Stress Induced Cardiomyopathy with Midventricular Ballooning: A Rare Variant.

Stress cardiomyopathy (SCM) also referred to as the “broken heart syndrome” is a condition in which intense emotional or physical stress can cause fulminant and reversible cardiac muscle weakness. SCM most commonly involves the apical segment of left ventricle but newer and rare variants have recently been seen reported. We here report a case of rare midventricular variant of stress related cardiomyopathy. A 72-year-old female with past medical history, only significant for SVT, presented with an episode of severe substernal chest pain while hiking with her husband. She felt a significant heaviness in her chest and was short of breath. During her hospitalization she was found to have positive cardiac enzymes. EKG showed 1 mm downsloping ST segment changes. Ventriculogram during left heart catheterization revealed dyskinetic midventricle. Patient was diagnosed with midventricular SCM. The patient was placed on ACE inhibitor and beta-blocker and discharged in a well-compensated state. We suggest identifying these patients by standard lab testing, electrocardiography, echocardiography, and left heart coronary angiography and ventriculography. Management of this unique entity is similar to the other variants with close observation and treatment of accompanying heart failure, valvular dysfunction, and any arrhythmias that may develop.

Takotsubo cardiomyopathy triggered by lateral wall ST-segment elevation myocardial infarction

We herein report the case of a 72-year-old female with a lateral wall acute myocardial infarction (MI) complicated by takotsubo cardiomyopathy (TC). The patient presented with “severe” chest pain lasting for one hour. She did not experience any obvious emotional or physical stress preceding the chest pain. An admission electrocardiogram showed ST-segment elevation in leads I, aVL, and V6 and ST-segment depression in leads II, III, aVF, and V1. Emergent coronary angiography showed total occlusion of the obtuse marginal branch. Subsequently, primary percutaneous old balloon angioplasty followed by everolimus-eluting stenting was performed. Left ventriculography performed immediately after final coronary angiography revealed hypokinesis in the lateral wall and mid-ventricular ballooning. The electrocardiographic findings and left ventricular wall motion later normalized. Cardiac magnetic resonance imaging showed late gadolinium enhancement in the lateral wall. In conclusion, to the best of our knowledge, this is the second case report of TC triggered by an acute MI, which provides further evidence that an acute MI can potentially trigger TC.<Learning objective: Takotsubo cardiomyopathy (TC) usually develops after exposure to an acute emotional or physical stressor in postmenopausal females. There is only one case report of TC triggered by an acute myocardial infarction (MI), a condition that is frequently associated with emotional stress. This second case report of TC triggered by an acute MI provides further evidence that an acute MI can potentially trigger TC.>

A case of atypical takotsubo cardiomyopathy with a midventricular ballooning

A case of atypical takotsubo cardiomyopathy with a midventricular ballooning