Reversible Left Ventricular Wall Motion Research Articles

Exploratory Review of the Takotsubo Syndrome and the Possible Role of the Psychosocial Stress Response and Inflammaging.

Takotsubo syndrome (TTS) is a cardiomyopathy that clinically presents as a transient and reversible left ventricular wall motion abnormality (LVWMA). Recovery can occur spontaneously within hours or weeks. Studies have shown that it mainly affects older people. In particular, there is a higher prevalence in postmenopausal women. Physical and emotional stress factors are widely discussed and generally recognized triggers. In addition, the hypothalamic-pituitary-adrenal (HPA) axis and the associated glucocorticoid-dependent negative feedback play an important role in the resulting immune response. This review aims to highlight the unstudied aspects of the trigger factors of TTS. The focus is on emotional stress/chronic unpredictable mild stress (CUMS), which is influenced by estrogen concentration and noradrenaline, for example, and can lead to changes in the behavioral, hormonal, and autonomic systems. Age- and gender-specific aspects, as well as psychological effects, must also be considered. We hypothesize that this leads to a stronger corticosteroid response and altered feedback of the HPA axis. This may trigger proinflammatory markers and thus immunosuppression, inflammaging, and sympathetic overactivation, which contributes significantly to the development of TTS. The aim is to highlight the importance of CUMS and psychological triggers as risk factors and to make an exploratory proposal based on the new knowledge. Based on the imbalance between the sympathetic and parasympathetic nervous systems, transcutaneous vagus nerve stimulation (tVNS) is presented as a possible new therapeutic approach.

Plasma Epinephrine Level and its Causal Link to Takotsubo Syndrome Revisited: Critical Review with a Diverse Conclusion.

Takotsubo syndrome (TS) is a recognized acute cardiac syndrome with a clinical presentation resembling that of an acute coronary syndrome (ACS). The defining feature of TS is the reversible left ventricular wall motion abnormality (LVWMA), which has a unique circumferential pattern resulting in a conspicuous ballooning of the left ventricle during systole, and extending beyond the coronary artery supply territory. The pathogenesis of TS is still elusive and several pathophysiological mechanisms have been proposed. A common portrayal of the syndrome in the literature is that the disease is characterized by massive surge of plasma catecholamines including epinephrine. Based on the assumption of massive plasma epinephrine elevation, some investigators hypothesized that the circulatory plasma epinephrine plays a pivotal role in the pathogenesis of TS. One typical such hypothesis is epinephrine induced switch in signal trafficking causing apical or mid-apical ballooning in TS. In-depth analysis of the literature reveals that no study with certainty has shown "massive" plasma epinephrine elevations in TS. Furthermore, the literature evidences challenging the epinephrine-induced switch in signal trafficking are substantial. In this review, sufficient data, indicating that the plasma epinephrine in TS is either normal or moderately elevated in all studies, are provided. Noteworthy, epinephrine may act as a trigger factor for TS-induction but there is no evidence for a direct causal link between epinephrine and TS.

Successful treatment of cerebral emboli with tissue plasminogen activator in a patient with takotsubo cardiomyopathy: A case report

Takotsubo cardiomyopathy is a cardiac syndrome characterized by reversible left ventricular wall motion abnormalities. It mimics the acute coronary syndrome; however, significant obstructive coronary artery disease is absent. The prognosis is relatively favorable in many cases, but complications may occur during the acute stage. Herein, we present a case of takotsubo cardiomyopathy in a 76-year-old woman. Three days after admission for persistent chest pains, the patient suddenly developed right hemiplegia, right homonymous hemianopsia, and aphasia. By diffusion-weighted magnetic resonance imaging and magnetic resonance angiography, we diagnosed acute-phase cerebral infarction caused by abrupt occlusion of the left middle cerebral artery by a thrombus, and treated it with intravenously administered tissue plasminogen activator. Three hours afterward, the patient's condition improved considerably. She was discharged 15 days after admission without any neurological sequelae. Thus, we show that takotsubo cardiomyopathy complicated by cerebral emboli can be successfully treated using tissue plasminogen activator.<Learning objective: Serious complications sometimes occur during the acute stage of takotsubo cardiomyopathy. Cerebral thromboembolisms are relatively common complications of takotsubo cardiomyopathy that require careful observation during acute phase, and anticoagulant therapy needs to be considered. In case of cerebral emboli, rapid treatment by tissue plasminogen activator infusion may lead to a favorable prognosis.>

Recurrent Left Ventricular Apical Ballooning Syndrome in a Patient with Pheochromocytoma

Transient left ventricular apical ballooning syndrome is characterized by reversible left ventricular wall motion abnormalities, chest pain or dyspnea, ST-segment elevation, and mild elevation of cardiac enzyme levels in the absence of obstructive coronary artery disease. The pathophysiology of the syndrome is still unknown. The probable mechanism is supposed to be a catecholamine discharge. We report the case of a 66-year-old woman with recently diagnosed pheochromocytoma who presented with chest pain and ST-segment elevation. Coronary angiography revealed normal coronaries and apical dyskinesia at ventriculography. A similar episode of chest pain occurred 4 years ago with same angiographic findings and reversible inferobasal akinesia. In-hospital course was uneventful and the patient was discharged from the hospital 4 days later with treatment of aspirin 1 × 100 mg, metoprolol 1 × 50 mg, lisinopril 1 × 10 mg, and atorvastatin 1 × 20 mg. At 2 years follow-up after the event, the patient remained asymptomatic.

An Atypical Case of Reverse Takotsubo Cardiomyopathy During General Anesthesia in a 30-Year-Old Male With Post-Traumatic Stress Disorder

TAKOTSUBO CARDIOMYOPATHY, also referred to as transient left ventricular ballooning syndrome or stress-induced cardiomyopathy, describes a rapid-onset, yet reversible systolic dysfunction that typically is triggered by an acute, stressful event. The pathophysiology is not completely understood, and similar presentations have been described as a result of the endocrine crisis of pheochromocytoma, 1 Iga K. Gen H. Tomonaga G. et al. Reversible left ventricular wall motion impairment caused by pheochromocytoma—A case report. Jpn Circ J. 1989; 53: 813-818 Crossref PubMed Scopus (42) Google Scholar subarachnoid hemorrhage, 2 Pollick C. Cujec B. Parker S. et al. Left ventricular wall motion abnormalities in subarachnoid hemorrhage: An echocardiographic study. J Am Coll Cardiol. 1988; 12: 600-605 Abstract Full Text PDF PubMed Scopus (192) Google Scholar and Guillain-Barré syndrome. 3 Iga K. Himura Y. Izumi C. et al. Reversible left ventricular dysfunction associated with Guillain-Barre syndrome—An expression of catecholamine cardiotoxicity?. Jpn Circ J. 1995; 59: 236-240 Crossref PubMed Scopus (73) Google Scholar A wide heterogeneity of presentation suggests that multiple overlapping mechanisms such as neurogenic catecholamine-induced myocardial stunning, 4 Wittstein I.S. Thiemann D.R. Lima J.A. et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005; 352: 539-548 Crossref PubMed Scopus (2324) Google Scholar microvascular dysfunction, 5 Bybee K.A. Prasad A. Barsness G.W. et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with transient left ventricular apical ballooning syndrome. Am J Cardiol. 2004; 94: 343-346 Abstract Full Text Full Text PDF PubMed Scopus (482) Google Scholar and multivessel epicardial spasm 6 Dote K. Sato H. Tateishi H. et al. Myocardial stunning due to simultaneous multivessel coronary spasms: A review of 5 cases. J Cardiol. 1991; 21: 203-214 PubMed Google Scholar , 7 Gianni M. Dentali F. Grandi A.M. et al. Apical ballooning syndrome or takotsubo cardiomyopathy: A systematic review. Eur Heart J. 2006; 27: 1523-1529 Crossref PubMed Scopus (1098) Google Scholar may play a role. Symptoms mimic an ST-segment elevation myocardial infarction. Patients present with ischemic electrocardiographic changes, reduced left ventricular ejection fraction, and a balloon-like contractility pattern that portrays a unique wall-motion abnormality that extends beyond the myocardial territory of a single coronary artery. The classic form presents as transient apical ballooning with basal hypercontractility. In more rare cases of reverse Takotsubo, the opposite is observed—transient dilatation of the basal segments of the heart with hyperkinesis of the apex.

Takotsubo cardiomyopathy after delivery in an oestrogen-deficient patient

Takotsubo cardiomyopathy is characterised by a reversible left ventricular wall motion abnormality that is observed as apical ballooning without significant coronary arterial stenosis; it occurs predominantly in postmenopausal women. Here, we report a case of Takotsubo cardiomyopathy after delivery in a patient with oestrogen deficiency due to Turner's syndrome. This case shows the pathogenic role of an inadequate oestrogen level in Takotsubo cardiomyopathy.

A case of takotsubo cardiomyopathy associated with epileptic seizure: reversible left ventricular wall motion abnormality and ST-segment elevation

A 59-year-old woman was admitted for consciousness disturbance. She had a history of endocranial operation for astrocytoma. Her electrocardiogram showed ST-segment elevation indicative of acute myocardial infarction. Emergency coronary angiography showed normal coronary arteries, whereas left ventriculography showed extensive severe hypokinesis in the anteroseptal and apical segments. Electroencephalography showed slow sharp wave activity from the left frontal lobe to the temporal lobe, and she was diagnosed as having status epilepticus. This is a rare case of takotsubo cardiomyopathy associated with epileptic seizure. Acute myocardial ischemia caused by impaired coronary microcirculation induced by abnormal catecholamine release is a possible cause of cardiac wall motion abnormality, as in our case.

Modulation of Ventricular Repolarization in Patients with Transient Left Ventricular Apical Ballooning: A Case Control Study

Even though diffuse T wave inversion and prolongation of the QT interval in the surface electrocardiogram (ECG) have been consistently reported in patients with transient stress-induced left ventricular apical ballooning (AB), ventricular repolarization has not yet been systematically investigated in this clinical entity. AB, an emerging syndrome that mimics acute ST-segment elevation myocardial infarction (MI), is characterized by reversible left ventricular wall motion abnormalities in the absence of obstructive coronary heart disease and significant QT interval prolongation. We prospectively enrolled 22 consecutive patients (21 women, median age 65 years) with transient left ventricular AB. A total of 22 age-, gender-, body-mass-index-, and left-ventricular-function-matched patients with acute anterior ST-segment elevation MI undergoing successful direct percutaneous coronary intervention for a proximal occlusion of the LAD, as well as 22 healthy volunteers served as control groups. Beat-to-beat QT interval and QT interval dynamicity were determined from 24-hour Holter ECGs, recorded on the third day after hospital admission. There were no significant differences in baseline clinical characteristics, except higher peak enzyme release in MI patients. Compared with MI patients, AB patients exhibited significantly prolonged mean QT intervals and rate-corrected QT intervals (QT: 418 +/- 37 vs 384 +/- 33 msec, P < 0.01; QTcBazett: 446 +/- 40 vs 424 +/- 35 msec, P < 0.05; QTcFridericia: 437 +/- 35 vs 412 +/- 31 msec, P < 0.05). Mean RR intervals tended to be higher in AB patients, without reaching statistical significance (877 +/- 96 vs 831 +/- 102 msec, P = NS). The linear regression slope of QT intervals plotted against RR intervals was significantly flatter in AB patients at both day- and nighttime (QT/RR slopeday: 0.18 +/- 0.04 vs 0.22 +/- 0.06, P < 0.01; QT/RR slopenight: 0.12 +/- 0.03 vs 0.17 +/- 0.05, P < 0.01). The present study is the first to demonstrate significant differences of QT interval modulation in patients with transient left ventricular AB and acute ST-segment elevation MI. Even though transient AB is associated with a significant QT interval prolongation, rate adaptation of ventricular repolarization (i.e., QT dynamicity) is not significantly altered, suggesting a differential effect of autonomic nervous activity on the ventricular myocardium in transient AB and in acute MI.

Tako-tsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage: an underappreciated ventricular dysfunction

Neurogenic stunned myocardium in aneurysmal subarachnoid hemorrhage (SAH) is associated with a wide spectrum of reversible left ventricular wall motion abnormalities and includes a subset of patients with a pattern of apical akinesia and concomitant sparing of basal segments called "tako-tsubo cardiomyopathy". After obtaining institutional review board approval, the authors retrospectively identified among all patients admitted to the Mayo Clinic's Neurological Intensive Care Unit between January 1990 and January 2005 those with aneurysmal SAH who had met the echocardiographic criteria for tako-tsubo cardiomyopathy. Among 24 patients with SAH-induced reversible cardiac dysfunction, the authors identified eight with SAH-induced tako-tsubo cardiomyopathy. All eight patients were women with a mean age of 55.5 years (range 38.6-71.1). Seven patients presented with a poor-grade SAH, reflected by a Hunt and Hess grade of III or IV. Four patients underwent aneurysm clip application, and four underwent endovascular coil occlusion. The initial mean ejection fraction (EF) was 38% (range 25-55%), and the mean EF at recovery was 55% (range 40-68%). Cerebral vasospasm developed in six patients, but cerebral infarction developed in only three patients. The authors describe the largest cohort with aneurysmal SAH-induced tako-tsubo cardiomyopathy. In the SAH population, tako-tsubo cardiomyopathy predominates in postmenopausal women and is often associated with pulmonary edema, prolonged intubation, and cerebral vasospasm. Additional studies are warranted to understand the complex mechanism involved in tako-tsubo cardiomyopathy and its intriguing relationship to neurogenic stunned myocardium.

Occurrence of Regional Left Ventricular Dysfunction in Patients Undergoing Standard and Biofeedback Dialysis

Cardiac failure and cardiovascular death are extremely prevalent in dialysis patients. Recurrent subclinical myocardial ischemia is important in the genesis of heart failure in nondialysis patients. We examined whether this phenomenon occurs in response to the stress of hemodialysis (HD). Eight patients prone to intradialytic hypotension were recruited for a randomized crossover study to compare the development of left ventricular regional wall motion abnormalities during standard (HD) and biofeedback dialysis. Patients underwent serial echocardiography with quantitative analysis to assess ejection fraction and regional left ventricular systolic function during both types of dialysis. Blood pressure and hemodynamic variables also were measured by using continuous pulse wave analysis. Forty-two new regional wall motion abnormalities developed in all 8 patients during HD compared with 23 regional wall motion abnormalities that developed in 7 patients during biofeedback dialysis (odds ratio, 1.8; 95% confidence interval, 1.1 to 3.0). The majority of regional wall motion abnormalities showed improvement in function by 30 minutes postdialysis. Overall mean regional function was significantly more impaired during HD (P = 0.022). At peak stress, ejection fraction (measured by percentage of change from baseline) was significantly lower during HD (P = 0.043). Blood pressure was higher during biofeedback dialysis, with significantly fewer episodes of hypotension (odds ratio, 2.0; 95% confidence interval, 1.01 to 4.4). Significantly smaller decreases in stroke volume and cardiac output and a greater increment in pulse rate were observed during biofeedback dialysis. This study shows that reversible left ventricular wall motion abnormalities develop during dialysis with ultrafiltration. We also show that this phenomenon can be ameliorated by the improved hemodynamic stability of biofeedback dialysis and therefore is a potential target for intervention.

P5-34: Transient left ventricular apical ballooning and arrhythmias: A case control study

Transient left ventricular apical ballooning (AB), an emerging syndrome that mimics acute ST-segment elevation myocardial infarction (MI), is characterized by reversible left ventricular wall motion abnormalities in the absence of obstructive coronary heart disease. In contrast to patients with acute myocardial infarction (MI) the in-hospital mortality rate seems to be low. Even though excess sympathetic activity plays a major part in the origin of this syndrome, arrhythmias have not yet been systematically investigated in this clinical entity.

An Association Between QTc Prolongation and Left Ventricular Hypokinesis During Sequential Episodes of Subarachnoid Hemorrhage

An Association Between QTc Prolongation and Left Ventricular Hypokinesis During Sequential Episodes of Subarachnoid Hemorrhage

A case of anorexia nervosa exhibited reversible left ventricular wall motion abnormality

A case of anorexia nervosa exhibited reversible left ventricular wall motion abnormality

Clinical aspects of silent myocardial ischemia in patients with angina and other forms of coronary heart disease

Silent myocardial ischemia is defined as objective evidence of myocardial ischemia occurring in the absence of symptoms in a patient who has either coronary artery disease or spasm. The largest number of patients with silent myocardial ischemia identified to date are those with effort angina, in whom silent episodes are at least three to four times as frequent as painful episodes. Since episodes of silent myocardial ischemia are not alarming to the patient and are likely to escape detection, their clinical importance must reside in their association with morbid events of ischemic heart disease. In fact, silent myocardial ischemia can result in silent myocardial infarction, sudden death, or other events. The detection of these episodes has the potential to provide clinicians with a more complete understanding of all the ischemic processes occurring in patients with angina or other forms of coronary disease. Silent myocardial ischemia can be detected by a variety of methods. Transient ischemic-type electrocardiographic abnormalities that occur without symptoms and that have been recorded during exercise testing or by means of ambulatory, coronary care unit, or telemetry monitoring may be used to document silent myocardial ischemia. Reversible left ventricular wall motion abnormalities without symptoms, observed at rest or during exercise radionuclide angiography, 2-D echocardiography, or contrast angiography, may also be used to document silent myocardial ischemia. However, only ambulatory electrocardiographic monitoring provides long-term evaluation that documents repeated episodes of silent myocardial ischemia outside of the laboratory. Controlled studies, directed specifically at preventing silent myocardial ischemia and/or its consequences in patients with angina, are limited. It has been determined, however, that both hourly administration of sublingual nitroglycerin and intravenous administration of isosorbide dinitrate are effective. Other studies examining the effects of beta blockers (propranolol, atenolol, and labetalol) in the treatment of angina have shown that their use also results in a reduced frequency of silent episodes, but that a large number of episodes persist. It has been observed that verapamil alone and nifedipine, either alone or in combination with a beta blocker, appear to significantly decrease silent myocardial ischemia in patients with angina. A major limitation of these studies is that treatment was not specifically titrated to reduce or eliminate silent myocardial ischemia. Recent studies from our laboratory suggest that if the dosing is modified, calcium channel blockers, as well as beta blockers, are effective in preventing silent myocardial ischemia in patients with angina. We also have found that percutaneous transluminal coronary angioplasty and coronary artery bypass grafting appear to be effective treatment for this condition. Thus, it can be seen that silent myocardial ischemia is a major problem for both patients and clinicians. Nevertheless, results using currently available methods, although limited, suggest that the problem can be detected and successfully managed in certain patient groups, particularly in those patients with angina pectoris.