Pattern Of Wall Motion Abnormality Research Articles

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acutephase.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE).

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Stress cardiomyopathy induced during dobutamine stress echocardiography.

Background:Catecholamines play a central role in pathogenesis of stress cardiomyopathy (SC). We aimed to review the clinical characteristics, procedural details and outcomes of patients with SC during dobutamine stress echocardiography (DSE).Methods/Results:A total of 20 adults [age 64±15 years, 80% women, 67% hypertension, 20% diabetes, 33% hypercholesterolemia, 19% chronic kidney disease, 13% known anxiety disorder] with SC during DSE were identified from local digital archives of our laboratory (n=3) or reports in English literature (n=17). Indication for DSE was suspected coronary artery disease (CAD) in all patients. Left ventricular (LV) ejection fraction was normal at baseline. SC developed at a blood pressure of 154±47/86±24 mmHg, heart rate of 130±17 bpm (88±10% predicted maximum) and peak rate-pressure product of 20559±3898 mmHg*bpm. ST segment elevation was seen in 65%. SC occurred at peak dobutamine infusion rate of 38±6 μg/kg/min in 85% and during recovery in 15%. Atropine [0.7±0.6 (0.25-2) mg] was given to 7 patients. LV ejection fraction dropped to 30±6% with apical (40%), apical and mid (45%) or basal and mid (10%) circumferential LV ballooning. One patient (5%) had a mixed pattern of wall motion abnormality. LV outflow tract obstruction developed in 15%. Major adverse cardiac events occurred in 7 (35%) and included death (n=1), congestive heart failure (n=2), hypotension (n=3) and atrial fibrillation with heart failure (n=1). At a mean follow up duration of 19±19 days, complete or partial recovery of LV wall motion abnormality was seen in 18 and 1 patient, respectively.Conclusion:SC uncommonly occurs during DSE. However, death and other adverse events (hypotension, heart failure and atrial fibrillation) may occur and require urgent attention. Once managed, complete recovery is expected in most patients.

P760Clinical profile of African-American and non-Hispanic caucasian patients with Takotsubo cardiomyopathy syndrome in a large urban hospital in the United States of America

Abstract Background Takotsubo (stress) cardiomyopathy is an acute reversible heart failure syndrome initially described in Japanese patients, but now well characterized in Caucasians patients in Europe or of European descent. An initial observation has suggested a lower incidence of Takotsubo in non-Caucasian subjects, particularly in the African-American (AA) population in the United States of America. The purpose of this study was to assess whether epidemiologic and clinical differences were present in Takotsubo in a large urban hospital in Virginia, USA. Methods We used an informatics-based system to query electronic health records (TriNetX, Cambridge, MA, USA) to search for cases of Takotsubo between 2010 and 2018 and a corresponding cohort of patients with non-ST segment elevation acute myocardial infarction (NSTEMI). We then performed a chart-level review of 160 cases and obtained additional clinical information including symptoms, risk factors, co-morbidities, and in-hospital outcomes. This retrospective study was approved by the Institutional Review Board of our institution. Results We identified 260 cases of Takotsubo and 6,270 of NSTEMI in the same time period (1:24, 4.2%). Being AA was associated with an odds ratio of Takotsubo versus NSTEMI of 0.38 [0.29–0.50] (P=0.0001). With further evaluation of patients with Takotsubo (N=160), AA (N=44, 27.2%) and Non-Hispanic Caucasian (C) (N=110, 67.9%) had no differences in age and sex. AA patients with Takotsubo however were more likely than C patients to be affected by type II diabetes mellitus (38.6% versus 14.5%, P=0.002, OR 3.70 [1.65–8.28]), have history of drug abuse (27.3% versus 9.1%, P=0.009, OR 3.75 [1.48–9.49]) and of cocaine use in particular (9.1% versus 0.9%, P=0.024, OR 11.0 [1.19–101.4]). The pattern of wall motion abnormality was not different between the 2 groups. AA patients presented with a lower ratio of brain natriuretic peptide (BNP) to troponin I (41.9 [12.7–258] pg./ml versus 281 [42–890] pg/ml, P=0.022). There was no significant difference of in-hospital mortality between the AA and C groups (9.1% versus 25%, respectively, OR 0.40 [0.13–1.24], P=0.11). Conclusions The incidence and clinical characteristics of Takotsubo (stress) cardiomyopathy appear to be different between African-American and Non-Hispanic Caucasian patients. African-American patients are more likely to have diabetes and illicit drug usage, but have a lower BNP/troponin I ratio. Both AA and Non-Hispanic Caucasian patients have similar in-hospital mortality.

Caring for the Takotsubo Cardiomyopathy Patient

Abstract Takotsubo cardiomyopathy is characterized by an atypical pattern of wall motion abnormalities seen during coronary angiography or echocardiogram as excessive abnormal movement of basal with midventricular and apical hypokinesis. These findings occur in the absence of obstructive coronary artery disease. The disorder was named due to its distinctive resemblance to traditional Japanese octopus fishing pots called tako-tsubo . The heart presents with a wide base and a long thin neck when viewed in an echocardiogram. Takotsubo cardiomyopathy was first identified in Japan in 1990 and, since then, has been gaining increased attention and being diagnosed worldwide.

Systemic lupus erythematosus cardiomyopathy—a case series demonstrating a reversible form of left ventricular dysfunction.

Myocarditis is reported to be a common postmortem finding of systemic lupus erythematosus (SLE). However, most case reports on SLE cardiomyopathy (CM) have not found evidence of myocarditis upon biopsy. Our aim was to characterize the nature, course, and reversibility of left ventricular (LV) dysfunction in patients with SLE. The records of 526 SLE patients were reviewed. Patients were included if: (1) at least 4 of 11 American College of Rheumatology criteria for SLE were met, (2) testing for erythrocyte sedimentation rate and hs-CRP were performed during hospitalization, and (3) echocardiogram demonstrated left ventricular ejection function (LVEF) <50%. We identified 14 patients meeting study criteria. Mean LVEF was 33.1 ± 9% upon presentation. The main echocardiographic pattern observed was generalized hypokinesis. Twelve patients demonstrated reversal of cardiomyopathy within 1 week, showing a mean improvement in LVEF of 21.0 ± 7%. Of these, 2 patients underwent coronary angiography demonstrating no evidence of obstructive coronary disease, and 1 underwent cardiac biopsy with no evidence of myocarditis. Four patients (29%) demonstrated improvement within 3 days. Two of the 14 patients died due to their underlying medical illness and did not have a repeat echocardiogram. The pattern of wall-motion abnormalities and reversibility demonstrated in the majority of these patients with SLE suggests an etiology more consistent with stress cardiomyopathy rather than myocarditis.

Neurogenic Stunned Myocardium and Takotsubo Cardiomyopathy Are the Same Syndrome: A Pooled Analysis

Neurogenic stunned myocardium (NSM) and Takotsubo cardiomyopathy (TCM) are two syndromes that coexist in the medical literature. They share many common features. We hypothesized that they, in fact, represent the same syndrome. We collected and analyzed case reports of transient left ventricular (LV) dysfunction in neurologic conditions. Cases were compared based on the diagnosis and then based on the pattern of wall motion abnormality. Of 112 cases, 61 were diagnosed as TCM and 37 as NSM, and in 14 cases, the authors used both terms. Overall, the patients with NSM were younger, and the severity of LV systolic dysfunction and timing of recovery was similar, as well as the prevalence of cardiac enzyme elevation. Pulmonary edema on presentation was more prevalent in patients with NSM while chest pain and ST-segment elevation was more common in patients with TCM. While only regional, predominantly apical, wall motion abnormality was described in TCM, some patients in the NSM group had global LV dysfunction. NSM and TCM likely share the same mechanism and pathologic substrate. Their natural course is almost identical. They both likely represent the same syndrome of stress-induced cardiomyopathy. Current definition of stress-induced cardiomyopathy includes only regional wall motion abnormalities. It should be expanded to include all varieties of wall motion abnormalities including global hypokinesis.

Apical and Midventricular Transient Left Ventricular Dysfunction Syndrome (Tako-Tsubo Cardiomyopathy) Frequency, Mechanisms, and Prognosis

The frequency and potential differences between patients with apical ("typical") and midventricular ("atypical") ballooning have not been described. Consecutive patients with the diagnosis of a troponin-positive acute coronary syndrome (ACS) were prospectively included into a registry (n = 3,265). Of those, 2,944 patients underwent left-heart catheterization and form the study population. Demographic, clinical, and angiographic data including assessment of microvascular dysfunction (Thrombolysis in Myocardial Infarction [TIMI] blush grade, corrected TIMI frame count), as well as clinical outcome were assessed in all patients. In patients with troponin-positive ACS, the frequency of transient cardiomyopathy was 1.2% (35 of 2,944 patients). Typical apical wall motion abnormality was observed in 21 of 35 patients (60%), as compared to an atypical (midventricular) pattern in 14 of 35 patients (40%). Both groups did not differ regarding demographic, clinical, laboratory, or angiographic parameters. Scintigraphy and PET studies were performed in 17 of 35 patients (49%) with transient cardiomyopathy, and showed a strong correlation between location of wall motion abnormality and myocardial metabolism defects, with a significantly higher apical decrease in glucose uptake in patients with a typical pattern. Transient cardiomyopathy affects approximately 1% of patients with a troponin-positive ACS. A typical apical wall motion abnormality is seen in only 60% of patients. Transient cardiomyopathy, also termed Tako-Tsubo cardiomyopathy, therefore should no longer be regarded as an exclusively apical ballooning syndrome, but rather a transient left ventricular dysfunction syndrome with an apical or midventricular pattern of wall motion abnormality.

Extent of Right and Left Ventricular Focal Wall-motion Abnormalities in Differentiating Transient Apical Ballooning Syndrome from Apical Dysfunction as a Result of Coronary Artery Disease

Differentiating the ventricular dysfunction caused by apical ballooning syndrome (ABS) from that caused by apical involvement in an acute coronary syndrome (ACS) currently requires coronary angiography. We sought to determine if echocardiography could differentiate these two syndromes by the extent of regional left ventricular (LV) and right ventricular (RV) dysfunction. The location of the hinge point between normal and hypokinetic wall motion for both the RV and LV was blindly determined in 8 patients with ABS and in 16 patients with an initial ACS secondary to obstruction of the left anterior descending coronary artery and an associated apical wall-motion abnormality. The hinge point for each wall was expressed as the percent of the wall from the apex to the annulus that was akinetic and determined for the RV free wall, the interventricular septum, and the LV anterior, inferior, and lateral walls. The ABS group as compared with the ACS group had a significantly greater RV involvement (48 +/- 20% vs 7.3 +/- 15%, P < .0001) and LV lateral wall involvement (53 +/- 18% vs 34 +/- 11%, P = .005). However, there were no differences between these groups for the other LV walls. An RV hinge point 40% from the apex was exceeded in 7 of 8 patients with ABS but in only 1 of 13 patients with ACS (P = .0005). In conclusion, patients with ABS had significantly greater RV free wall and LV lateral wall dysfunction as compared with patients with ACS. This pattern of wall-motion abnormalities, when present, could allow for an early presumptive and noninvasive diagnosis of ABS.

Apical ballooning without apical ballooning

A 63-year-old woman presented with a sudden exacerbation of chronic obstructive lung disease and elevated levels of cardiac troponin T (0.5 ng/mL). The electrocardiogram exhibited sinus tachycardia, P-pulmonale, and diffuse T-wave inversion. The echocardiogram displayed markedly impaired left ventricular function. In view of these diagnostic findings and ongoing dyspnoea, the patient was referred for emergency cardiac catheterization. Left ventricular angiography demonstrated a depressed ventricular function with an unusual pattern of wall motion abnormalities, characterized by a circular mid-ventricular balloon-like dyskinesis and marked apical …