Reversible Left Ventricular Dysfunction Research Articles

Reverse takotsubo cardiomyopathy in the setting of small bowel obstruction: a case report

Introduction and Importance: Stress cardiomyopathy refers to a syndrome of acute but reversible left ventricular dysfunction, often triggered by emotional or physical stress. Reverse takotsubo cardiomyopathy is an uncommon variant that occurs in about 5% of cases. Classically, it has been known to be following a catecholamine surge due to physical or emotional stress. This case highlights the importance for physicians to be aware of the possibility of developing a stress cardiomyopathy in patients with acute intrabdominal processes. Case Presentation: 41-year-old Caucasian female with was admitted with an acute small bowel obstruction. After failing conservative management, it was decided to proceed with surgery. After induction with anesthesia but prior to the surgeons first incision, the patient developed a tachyarrhythmia with hemodynamic compromise requiring the surgery to be aborted. That evening, she developed chest pain with concerns for an acute coronary syndrome. She was taken urgently to the for invasive angiography which demonstrated reverse takotsubo. Clinical Discussion: Intra-abdominal processes and intubation have previously been reported be catalyst for this disease process. This patient had multiple stressors including mechanical bowel obstruction and anesthesia after failing conservative management. The diagnosis was confirmed by coronary angiography and left ventriculogram, and followed up with repeat outpatient echocardiography. Conclusion: A case of small bowel obstruction that developed reverse takotsubo preceded by sustained ventricular tachycardia after intubation. The patient did well and had complete recovery cardiac function. Risk factors and underlining mechanism for the different variants of stress cardiomyopathy are not well understood, further investigation is warranted.

Outcome with pertuzumab, docetaxel, and trastuzumab (PTH) regimen in patients with HER2 positive metastatic breast cancer: Real-world data from a single center in India.

e13037 Background: Pertuzumab, Docetaxel and Trastuzumab (PTH) regimen constitutes one of the standard treatment regimens in human epidermal growth factor receptor-2 (HER2) positive metastatic breast cancer (MBC). The real-world outcomes of its use from the Indian sub-continent are lacking. Methods: We retrospectively reviewed the medical records of HER2-positive MBC treated with an upfront PTH regimen at the All India Institute of Medical Sciences, New Delhi, India, between Aug 2016 to July 2023. A total of six cycles of PTH [pertuzumab (840 mg loading followed by 420 mg), docetaxel (75 mg/m2), trastuzumab (8 mg/kg loading followed by 6 mg/kg) q21 days] were planned along with granulocyte-colony stimulating factor (GCSF) prophylaxis. Patients were continued on maintenance trastuzumab after 6 cycles (till disease progression) and hormonal agent if indicated. The primary outcome was progression-free survival (PFS). The secondary outcome was overall survival (OS), overall response rate (ORR) rates, and toxicity. Results: Eighty-seven were included with a median age of 48 years (range, 25-73). Overall, 38 (43.6%) patients had hormone-positive (estrogen receptor and or progesterone receptor) disease and 48 (55.17%) were premenopausal. Thirty-five (40.2%) patients had received prior adjuvant and neoadjuvant treatment. Eighty patients (91.5%) had visceral metastasis and the most common site was the liver followed by the lung. After a median follow-up of 36 months, the median PFS was 15 months and OS was 42 months. The ORR was 85.3% and complete response (CR) was observed in 14(16.09%) patients. The survival outcomes were significantly better among those with hormone-negative disease and among those who achieved CR after 6 cycles of PTH. Grade 3/4 toxicity was seen in 12% of patients which led to dose modification, interruption, and change in chemotherapy. Two patients developed reversible left asymptomatic ventricular systolic dysfunction. None of the patients developed congestive heart failure. The most common grade 3/4 toxicities were diarrhea in 8 (9.1%) patients, cutaneous rash in 2 (2.2%) patients and thrombocytopenia in 2 (2.2%) patients. There were two cases of febrile neutropenia. Conclusions: In a real-world context, PTH is an effective and well-tolerated regimen for in patients with HER2-positive MBC in India. Hormone-positive disease has poor survival compared with hormone negative disease.

Adrenaline bij de behandeling van anafylaxie: hard voor het hart

Adrenaline in the treatment of anaphylaxis: hard for the heart The cornerstone of the treatment of anaphylaxis is adrenaline. The European Resuscitation Council recommends rapid administration by intramuscular route. In addition to acting as a catecholamine on alpha-1, beta-1 and beta-2 adrenergic receptors, it also reduces mediator release from mast cells, decreases obstructive respiratory symptoms and prevents cardiovascular collapse. Serious adverse effects of adrenaline when used in the treatment of anaphylaxis are rare, but can be life-threatening. This case describes a stress-induced (Takotsubo) cardiomyopathy after the erroneous administration of adrenaline via intravenous route instead of intramuscularly in a patient with anaphylaxis. Takotsubo cardiomyopathy is seen in situations of acute stress or intense emotion, mainly in middle-aged women. Clinically, this disease resembles an acute coronary syndrome with an increase in cardiac markers, changes on the electrocardiography (ECG) and reversible left ventricular dysfunction. On a coronarography, however, the coronary arteries are shown to be patent. The exact aetiology is still uncertain. The patient in this case study underwent cardiac catheterisation to rule out primary coronary artery damage and subsequently received a drug treatment with an angiotensin-converting enzyme (ACE) inhibitor and a low-dose beta blocker, in combination with a cardiac rehabilitation programme. The follow-up via a transthoracic echocardiography 1 month later showed a complete recovery of the left ventricular function.

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

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

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

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

Acute Myocardial Infarction or Broken Heart with Takotsubo Cardiomyopathy? Realm of Mystification after Suicidal Hanging

Abstract Takotsubo cardiomyopathy is a rare immune-endocrinologic cause of acute and rapidly reversible left ventricular dysfunction, usually resembling acute myocardial infarction (AMI) and triggered by emotional or physical stress. We described a case of such syndrome in a 27-year-old female after an attempted suicidal hanging, whose initial clinical symptoms and electrocardiography (ECG) findings were misleading to AMI. On admission, the patient was unconscious and hypoxic. Echocardiography demonstrated a severe left ventricular systolic dysfunction with akinesis in the mid and anterior septum and apex (a typical ballooning pattern), which raised suspicion of takotsubo cardiomyopathy. Our patient developed chest pain, a day after the suicidal attempt. Emergent coronary angiography revealed no evidence of occlusion, confirmed diagnosis of takotsubo cardiomyopathy was made. The patient was managed with medical therapy. On a week later follow-up, the patient was totally asymptomatic with a reversal of ECG changes, and the left ventricular contractility was improved within 30 days.

Severity of Left Ventricular Dysfunction in Patients With Tachycardia-Induced Cardiomyopathy: Impacts on Remodeling After Atrial Flutter Ablation

Tachycardia-induced cardiomyopathy is defined as a reversible left ventricular (LV) systolic dysfunction (SeD) resulting from a sustained fast heart rate. LV remodeling in patients with severe LV dysfunction at diagnosis remains poorly understood. In this retrospective cohort study, we described LV remodeling in 50 patients who underwent atrial flutter ablation. These patients were divided into severe LV SeD (LV ejection fraction [EF] ≤30%) and LV nonsevere SeD (LVEF 31% to 50%) at baseline. All continuous variables are expressed as median and interquartile range. LVEF was 18% (13 to 25) and 38% (34 to 41) in the SeD (n=29) and LV nonsevere SeD (n=21) groups, respectively. At baseline, patients with SeD had higher LV end-diastolic diameter (56 [54 to 59] vs 49mm [47 to 52], p<0.01), LV end-systolic diameter (48 [43 to 51] vs 36mm [34 to 41], p<0.01), LV end-diastolic volume (71 [64 to 85] vs 56ml/m2 [46 to 68], p<0.01), LV end-systolic volume (56 [53 to 70] vs 36ml/m2 [27 to 42], p<0.01), and lower tricuspid annular plane systolic excursion (12 [10 to 13] vs 16mm [13 to 19], p<0.01). At last follow-up, LVEF was not statistically significantly different between groups. However, LV end-systolic diameter (36 [34 to 39] vs 32mm [32 to 34], p=0.01) and LV end-systolic volume (29 [26 to 35] vs 25ml/m2 [20 to 29], p=0.02) remained larger in the SeD group. Seven patients (14%), all from the SeD group, had a LVEF ≤35% 2months after rhythm control, and reverse remodeling was observed up to 9months. In conclusion, more than half of patients with tachycardia-induced cardiomyopathy and atrial flutter had LVEF ≤30% at baseline. LVEF recovery and LV remodeling were observed beyond 2months, highlighting the importance of rhythm control and early guideline-directed medical therapy in these patients.

Acute heart failure following pazopanib treatment: a literature review featuring two case reports.

Tyrosine kinase inhibitors (TKIs) have transformed cancer treatment but are associated with cardiovascular toxicity, including heart failure. This review examines the cardiotoxicity of pazopanib, a VEGFR-TKI, through two case reports and explores potential mechanisms. The importance of vigilant clinical monitoring to prevent cardiac dysfunction in cancer patients receiving pazopanib is emphasized. We present two cases of acute heart failure following pazopanib treatment. Case 1 involves a comorbidity-free, 62-year-old woman with metastatic renal cell carcinoma who experienced irreversible heart failure. In case 2, a 40-year-old woman with a history of anthracycline-containing chemotherapy developed reversible left ventricular systolic dysfunction following pazopanib discontinuation. Both patients received appropriate management for their heart failure symptoms. Case 1's condition rapidly deteriorated, leading to her unfortunate demise 3 months after starting pazopanib. In contrast, case 2's cardiac function improved after discontinuing pazopanib. The advent of TKIs has revolutionized cancer treatment, but their association with cardiovascular toxicity necessitates meticulous monitoring of patients. The cases presented here highlight the importance of recognizing and managing cardiotoxicity, particularly in patients without prior cardiovascular risk factors. Understanding the underlying mechanisms and risk factors for TKI-induced heart failure is crucial to optimize patient care and treatment outcomes. Oncologists should be vigilant in identifying clinical symptoms and closely monitoring cardiac function throughout TKI therapy.

Abstract 12829: Short- and Long-Term Outcomes of Takotsubo Syndrome and Acute Coronary Syndrome. A Meta-Analysis

Introduction: Takotsubo syndrome (TTS) is a condition characterized by reversible left ventricular dysfunction with typical regional wall motion abnormalities. Although the presentation mimics acute coronary syndrome (ACS), its exact pathophysiology is not known. Despite the transient nature of cardiac dysfunction in TTS, the prognosis remained uncertain, with mortality rates reportedly comparable to that of ACS. The aim of this study was to compare the outcomes between patients with TS and ACS through a meta-analysis. Methods: We systematically searched various electronic databases including PubMed, Embase, and Cochrane Library to identify relevant studies. The outcomes were pooled using the Hartung-Knapp-Sidik-Jonkman random effects model, and the results were presented as odds ratio (OR) with their corresponding 95% confidence interval (CI). Results: 11 studies with 3,455,862 (95,165 TTS and 3,360,697 ACS) patients were included in the final analysis. The risk of in-hospital mortality (OR, 0.61(95%CI: 0.42-0.89), P=0.01), 30-day mortality (OR, 0.62(95%CI: 0.48-0.81), P&lt;0.001) were significantly lower in the TTS group compared to the ACS group. There was no difference in the risk of cardiogenic shock (OR, 0.87(95%CI: 0.54-1.42), P=0.58) between both groups. The risk of long-term all-cause mortality (OR, 1.10(95%CI: 0.61-1.97), P=0.75) was comparable between both groups, with significantly higher non-cardiovascular cause of mortality (OR, 2.40(95%CI: 1.83-3.15), P&lt;0.001) among the TTS group compared to the ACS group. Conclusions: This study suggests a favorable short-term prognosis for TTS patients compared to ACS patients, but a comparable risk of long-term mortality. It is noteworthy that TTS patients have a higher risk of non-cardiovascular mortality. Further studies are warranted to explore the factors contributing to the increased risk of non-cardiovascular mortality in TTS patients in order to improve outcomes in this population.

The Utility of Low-Dose-Dobutamine Stress Echocardiography in Patients with Heart Failure with Reduced Ejection Fraction: An Update.

Despite significant advancements in medical therapy, heart failure with reduced ejection fraction (HFrEF) continues to be a significant cause of death and disability. Reversible ischaemic left ventricular dysfunction due to viable myocardium is one such contributing factor. In these cases, coronary revascularization has shown promise in improving left ventricular function and prognosis. For patients with HFrEF and wide QRS, cardiac resynchronization therapy (CRT) is an effective option to address electromechanical dyssynchrony. However, approximately 30% of patients do not respond positively to CRT, highlighting the need to refine candidate selection for this treatment. In some patients with reduced HFrEF, there is a condition known as classical low-flow, low-gradient aortic stenosis (AS) that may be observed. This condition is characterized by a low transaortic flow, which leads to reductions in both the transaortic mean gradient and aortic valve area. Decision-making regarding revascularization, CRT, and pharmacological treatment play a crucial role in managing HFrEF. Cardiac imaging can be valuable in guiding decision-making processes and assessing the prognosis of patients with HFrEF. Among the imaging modalities, dobutamine stress echocardiography has come a long way in establishing itself as a feasible, safe, effective, relatively cheap non-invasive technique. The aim of this review is to explore the current literature on the utility of low-dose stress echocardiography in diagnosing and prognosticating patients with HFrEF.

Left Ventricular Dysfunction Associated With Brain Death: Results From the Donor Heart Study.

Left ventricular dysfunction in potential donors meeting brain death criteria often results in nonuse of donor hearts for transplantation, yet little is known about its incidence or pathophysiology. Resolving these unknowns was a primary aim of the DHS (Donor Heart Study), a multisite prospective cohort study. The DHS enrolled potential donors by neurologic determination of death (n=4333) at 8 organ procurement organizations across the United States between February 2015 and May 2020. Data included medications administered, serial diagnostic tests, and transthoracic echocardiograms (TTEs) performed: (1) within 48 hours after brain death was formally diagnosed; and (2) 24±6 hours later if left ventricular (LV) dysfunction was initially present. LV dysfunction was defined as an LV ejection fraction <50% and was considered reversible if LV ejection fraction was >50% on the second TTE. TTEs were also examined for presence of LV regional wall motion abnormalities and their reversibility. We assessed associations between LV dysfunction, donor heart acceptance for transplantation, and recipient 1-year survival. An initial TTE was interpreted for 3794 of the 4333 potential donors by neurologic determination of death. A total of 493 (13%) of these TTEs showed LV dysfunction. Among those donors with an initial TTE, LV dysfunction was associated with younger age, underweight, and higher NT-proBNP (N-terminal pro-B-type natriuretic peptide) and troponin levels. A second TTE was performed within 24±6 hours for a subset of donors (n=224) with initial LV dysfunction; within this subset, 130 (58%) demonstrated reversibility. Sixty percent of donor hearts with normal LV function were accepted for transplant compared with 56% of hearts with reversible LV dysfunction and 24% of hearts with nonreversible LV dysfunction. Donor LV dysfunction, whether reversible or not, was not associated with recipient 1-year survival. LV dysfunction associated with brain death occurs in many potential heart donors and is sometimes reversible. These findings can inform decisions made during donor evaluation and help guide donor heart acceptance for transplantation.

P436 ASSOCIATION BETWEEN REVERSE–TAKO–TSUBO E NEUROLOGICAL DISORDER

Abstract Reverse–Tako–tsubo (r–TTC) is a rare variant of Tako–tsubo syndrome (TTC). TTC is characterized by transient and reversible left ventricular systolic dysfunction, for which an emotional or physical stressful trigger can usually be identified. Clinically, it mimics an acute myocardial infarction, with elevation of myocardial cytonecrosis enzymes and no obstractive coronary artery stenosis. On imaging, r–TTC is characterized by hypokinesia of the mid–basal regions associated with hyperkinesia of the apical region that resolves spontaneously. Case report: 78–year–old female affected by cerebral atrophy, leukoencephalopathy, cognitive impairment, behavior disorders. Reported episode of loss of consciousness lasting several minutes, associated with spontaneously resolving tremors and left hemisome hyposthenia. When she arrived in the emergency room, the haematological tests found high troponin values. On CT brain without contrast, no evidence of alterations of the encephalic tissues referable to acute lesions, but it showed of diffuse supratentorial leukoaraiosis and widening of the cerebrospinal fluid spaces on an atrophic basis. The neurological evaluation excludes the presence of a seizure. The electrocardiogram showed diffuse negative T waves and QTc 636 ms. The coronary angiography didn’t show significant coronary arteries stenosis and the ventriculography showed normal ventricular dimensions with total akinesia of the mid segments and normokinesia of the apical region with an ejection fraction of 50%. With these findings a diagnosis of mid left ventricular Tako–tsubo (r–TTC) was made. Transthoracic color Doppler echocardiography confirmed the alterations of the left ventricular kinetics observed by ventriculography. Conclusions compared to CTT, r–TTC is associated with a lower decline in global systolic function and, as reported in the literature, there is a greater connection to neurological insults as triggering factors, such as episodes of aneurysmal subarachnoid hemorrhage, brain surgery, ischemic stroke seizures and traumatic brain injury. The underlying mechanisms are still unknown, a crucial role in catecholamine–induced cardiotoxicity, coronary microvascular dysfunction or coronary vasospasm and/or estrogen deficiency is hypothesized.

Changes in CMR findings over time following acute Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTS) is characterized by acute reversible left ventricular dysfunction showing typical left ventricular apical ballooning in the absence of obstructive coronary artery disease. Cardiac magnetic resonance (CMR) provides functional and inflammatory findings in contrast with the absence of late gadolinium enhancement (LGE). TTS generally heals within the first two weeks after the onset of symptoms, with the ECG and echocardiogram normalizing. However, data on CMR dynamics are scarce. In the present study, we aimed to describe how CMR findings change over time in acute TTS. Between December 2008 and May 2021, we retrospectively included all the patients hospitalized in the tertiary University Hospital of Angers, France who underwent CMR and received a diagnosis of acute TTS. Sixty-two patients fulfilled the diagnostic criteria from the 2018 ESC international expert consensus and underwent CMR. Patients were classified into three groups based on the delay between their first day of hospitalization and their assessment using CMR: less than five days (n = 31, 50%), between 5 and 15 days (n = 16, 25.8%), and more than 15 days [median 27 days (IQR: 20–36)] (n = 15, 24.2%). Compared to the 0–5 d group, the patients in the > 15 d group showed resolution of the LVEF alterations (55.9 ± 10.7 vs. 44.8 ± 13.3, P = 0.07), less apical akinesia (40% vs. 83%, P = 0.01) and normalized apical T2 values (44.5 ± 3.5 vs. 57 ± 2, P = 0.049). T1 and T2 quantitative measurements showed a base-to-apex gradient in 88.2% and 85.7% of patients, irrespective of the delay (P = 0.12 and P = 0.88). When CMR cannot be performed early after the onset of a suspected TTS, wall motion abnormalities disappear, and LVEF alteration resolve. However, a parametric assessment searching for a base-to-apex gradient in T1 and T2 values with higher apical values may be helpful to confirm the diagnosis. Main CMR findings at different time points (Fig. 1).

Acute neurogenic stunned myocardium in a patient with Guillain-Barré syndrome: case report.

A 65-year-old man with GBS presented with reversible left ventricular systolic failure. On first presentation, our patient had no history or indications of heart malfunction. During the clinical manifestation of his autonomic dysfunction, he had electrocardiographic alterations, modestly increased cardiac enzymes, significant left ventricular systolic dysfunction, and segmental wall motion irregularity. Once the initial episode was over, these anomalies and his symptoms resolved quickly. We believe the reversible left ventricular dysfunction was caused by the toxic impact of elevated catecholamines as well as transiently injured sympathetic nerve endings in the myocardium, which was apparently caused by GBS. We recommend that echocardiography be performed in patients who exhibit clinical signs of autonomic dysfunction, particularly if they are associated with abnormal electrocardiographic findings, cardiac enzyme elevation, or hemodynamic instability, so that appropriate medical therapy can be instituted as soon as possible. GBS is a not a very rare situation in our context. Thus, doctors are supposed to know the life-threatening complications such as neurogenic stunned myocardium and be prepared to dodge it.

Takotsubo syndrome: more frequent in women, more dangerous in men.

Takotsubo syndrome (TTS) is an acute myocardial disease characterized by reversible left ventricular dysfunction, in the absence of obstructive coronary artery disease, caused by adrenergic overactivity and associated with non-negligible morbidity and mortality. Takotsubo syndrome, by far more frequent in women, who account for 9 out of 10 cases, is generally triggered by intense psychoemotional stress. In men, TTS has different, though not yet fully defined, characteristics and clinical course. In fact, men have a higher prevalence of a physical trigger and comorbidities, such as bronchopulmonary or cerebral pathologies, diabetes mellitus, and malignant neoplasms. The hospital course is burdened by a higher rate of cardiogenic shock and mortality. The long-term prognosis is also less favourable in men. Takotsubo syndrome in men characterizes a higher-risk phenotype, which requires close monitoring during hospitalization and careful surveillance during follow-up.

Impact of intra-aortic balloon counterpulsation on all-cause mortality among patients with Takotsubo syndrome complicated by cardiogenic shock: results from the German-Italian-Spanish (GEIST) registry.

Takotsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction and can be complicated by cardiogenic shock (CS). However, few data are available on optimal care in TTS complicated by CS. Aim of this study was to evaluate short- and long-term impact of intra-aortic balloon pumping (IABP) on mortality in this setting. In a multi-centre, international registry on TTS, 2248 consecutive patients were enrolled from 38 centres from Germany, Italy, and Spain. Of the 2248 patients, 212 (9.4%) experienced CS. Patients with CS had a higher prevalence of diabetes (27% vs. 19%), male sex (25% vs. 10%), and right ventricular involvement (10% vs. 5%) (P < 0.01 in all cases). Forty-three patients with CS (20% of 212) received IABP within 8 h (interquartile range 4-18) after admission. No differences in terms of age, gender, cardiovascular risk factors, and admission left ventricular ejection fraction were found among patients with and without IABP. There were no significant differences in terms of 30-day mortality (16% vs. 17%, P = 0.98), length of hospitalization (18.9 vs. 16.7 days, P = 0.51), and need of invasive ventilation (35% vs. 41%, P = 0.60) among two groups: 30-day survival was not significantly different even after propensity score adjustment (log-rank P = 0.73). At 42-month follow-up, overall mortality in patients with CS and TTS was 35%, not significantly different between patients receiving IABP and not (37% vs. 35%, P = 0.72). In a large multi-centre observational registry, the use of IABP was not associated with lower mortality rates at short- and long-term follow-up in patients with TTS and CS.

285 BIVENTRICULAR TAKO-TSUBOSYNDROME ASSOCIATED WITH SYNCOPE AND UNCONSCIOUSNESS

Abstract A 58-years old woman came to the emergency department due to syncope; she had been found lying on the ground in her residence. At the admission the patient was unconscious but had preserved blood pressure 120/80 mmHg. CT brain scan was negative for hemorrhage. Admission ECG showed a 52 b/m sinus bradycardia, elevated antero-septal ST segment and prolonged QT interval. Diagnosis of antero-septal STEMI was made and a coronary angiogram performed via right femoral access showed mild atheromasia in the absence of angiographically significant lesions. Bedside echocardiogram showed severe left ventricular dysfunction (LVEF 35%) with akinesia of apical and mid-ventricular segments. The right ventricle presented a marked hypocontractility of the apical region and a preserved kinetics of the basal portion (TAPSE 22 mm). There was also a moderate mitral regurgitation and a mild tricuspid regurgitation with a sPAP of 50 mmHg (40+10). On blood sampling, high-sensitivity troponin was slightly elevated (3950 pg/ml) and marked hyponatriemia (117 mmol/l) and slight hypokalemia (3.1 mmol/l) were noted. The echocardiogram on the third day showed an improvement in global and segmental kinetics of left ventricle with an estimated EF of 45% and persistence of a mild hypocontractility of the apex of right ventricle. During her hospital stay, her cognitive state gradually improved and she remained asymptomatic without evidence of arrhythmic events on monitoring. The ECG evolved on days with normalization of the ST-T tract, negative T wave in the anterior region and prolonged QTc interval. The pre-discharge echocardiogram showed a recovery of biventricular kinetics with an estimated EF of 50%. The presence of a transient abnormality in biventricular wall motion beyond a single epicardial coronary artery perfusion territory with new electrocardiographic change met the diagnostic criteria of Tako-tsubo Syndrome defined by Mayo Clinic criteria. The electrocardiogram on the day of discharge showed a 55 b/m sinus bradycardia with a negative T wave from V1 to V4. Tako-tsubo syndrome (TTS) is an acute and reversible left ventricular dysfunction that improves spontaneously within days or weeks and is often preceded by emotional or physical stress. Biventricular involvement in TTS is typically identified on imaging studies such as echocardiography and MRI. TTS with RV involvement is associated with a higher rate of in-hospital mortality and long-term adverse clinical events than isolated LV TTS. In our clinical case, biventricular involvement was associated with a severe clinical presentation (syncope and unconsciousness). This case shows that biventricular Tako-tsubo is a clinical scenario that requires intensive care monitoring and strict cardiological evaluation.

438 INCIDENT HYPOCHLOREMIA AMONG PATIENTS WITH TAKOTSUBO SYNDROME: SHORT- AND LONG-TERM OUTCOME. RESULTS FROM A MULTICENTER PROSPECTIVE REGISTRY.

Abstract Background Takotsubo syndrome (TTS) is an acute heart failure syndrome featured by a reversible left ventricular systolic dysfunction with significant rate of in- and out-of-hospital mayor cardiac adverse events (MACE). Aim of the study To evaluate the possible role of hypochloremia as prognostic marker at short- and long-term follow-up in subjects with TTS. Methods 305 consecutive patients were enrolled in a multicenter international registry. Clinical, laboratory and echocardiographic evaluations were performed at admission and during hospitalization. Incident hypochloremia (serum chloride level below 97 mEq/l) during hospitalization was recorded. In-hospital MACE, short- and long-term mortality was recorded. Results Mean admission serum chloride levels were 102±5 mEq/l. 97 out of 305 (37%) patients experienced incident hypochloremia. Patients with incident hypochloremia were older (78±10 vs 73±12 years, p=0.01), had lower admission LVEF (34±8% vs 37±8%, p=0.009), and longer hospital stay (9±4 vs 7±4 days, p=0.0003). During hospitalization patients with incident hypochloremia had higher rates of complication (45% vs 32%, p=0.01), lower levels of natremia and azotemia at admission and discharge. At long term follow-up incident hypochloremia was associated with increased risk of MACE (49% vs 32%, p=0.005) and death (42% vs 24%, p=0.002, log rank p&amp;lt;0.01). Conclusion Incident hypochloremia is a common finding among hospitalized patients with TTS, associated with higher risk of in-hospital events and long-term MACE and death.

391 NEUROLOGICAL DISORDERS AND TAKOTSUBO SYNDROME: CLINICAL FEATURES AND OUTCOMES. RESULTS FROM A MULTICENTER PROSPECTIVE EUROPEAN REGISTRY OF 2300 PATIENTS.

Abstract Background and aims Takotsubo syndrome (TTS) is an acute heart failure syndrome featured by a reversible left ventricular systolic dysfunction. However, few data have been reported about prevalence of non-cardiovascular comorbidities as chronic neurological disorders in TTS patients. Aim of this study was to compare clinical features, short- and long-term outcome among TTS patients with history of neurological disorder. Methods 2301 patients with TTS were enrolled in a multicenter prospective European registry from July 2002 to November 2021. Clinical features, in- and out-of-hospital MACE, laboratory and imaging data were collected and a long-term follow-up was performed. Results Prevalence of history of neurological disorder was 17% (n= 400 pts). Most represented neurological conditions were previous cerebrovascular disorders (ischemic stroke and transient ischemic attack, 36.2%), followed by neurodegenerative disorders (30.7%, including cognitive disorders and motion disorders), tensive migraine (10%) and epilepsy (9.5%). Neurological Patients developed TTS more frequently after a physical trigger (46.2% vs 33.8%, p&amp;lt;0.01). Sepsis (10%), acute neurological trigger (9.5%) and extreme activity/trauma (8.5%) where the type of physical trigger more prevalent. During hospitalization neurological patients had longer in-hospital stay (10±11 days vs 8±8 days, p&amp;lt;0.01) and experienced more often in-hospital complications (27% vs 16%, p=0.0001) mainly driven by cardiogenic shock and in-hospital death (12% vs 7.6%; 6.5% vs 2.8%, respectively p&amp;lt;0.01). Long-term mortality was higher in patients with history of neurological disorders (23.5% vs 10%, p&amp;lt;0.01), with a mean follow up of 2.5 ± 5.8 years. Conclusions Patients with history of neurological disorders and TTS have different clinical features and worse prognosis with higher short-term and long-term mortality.

Myocardial Viability Testing in the Management of Ischemic Heart Failure.

Although major advances have occurred lately in medical therapy, ischemic heart failure remains an important cause of death and disability. Viable myocardium represents a cause of reversible ischemic left ventricular dysfunction. Coronary revascularization may improve left ventricular function and prognosis in patients with viable myocardium. Although patients with impaired left ventricular function and multi-vessel coronary artery disease benefit the most from revascularization, they are at high risk of complications related to revascularization procedure. An important element in selecting the patients for myocardial revascularization is the presence of the viable myocardium. Multiple imaging modalities can assess myocardial viability and predict functional improvement after revascularization, with dobutamine stress echocardiography, nuclear imaging tests and magnetic resonance imaging being the most frequently used. However, the role of myocardial viability testing in the management of patients with ischemic heart failure is still controversial due to the failure of randomized controlled trials of revascularization to reveal clear benefits of viability testing. This review summarizes the current knowledge regarding the concept of viable myocardium, depicts the role and tools for viability testing, discusses the research involving this topic and the controversies related to the utility of myocardial viability testing and provides a patient-centered approach for clinical practice.