Transient Apical Ballooning Syndrome Research Articles

Out-of-hospital cardiac arrest caused by transient left ventricular apical ballooning syndrome

We describe a case of out-of-hospital cardiac arrest due to ventricular fibrillation in a patient with transient left ventricular apical ballooning syndrome. Our report confirms that left ventricular apical ballooning may have the same complications of myocardial infarction, adding the early ventricular fibrillation to the previous findings of left ventricular wall rupture, ventricular arrhythmias during hospitalization and complete atrio-ventricular block. Moreover, left ventricular apical ballooning may have different and unusual clinical onsets, including sudden cardiac death due to ventricular tachyarrhythmias in the absence of associated symptoms. Therefore, in our opinion left ventricular apical ballooning may be considered as a possible cause of sudden death in otherwise healthy women.

The Coronary Flow Reserve Is Transiently Impaired in Tako-Tsubo Cardiomyopathy: A Prospective Study Using Serial Doppler Transthoracic Echocardiography

The clinical features of tako-tsubo cardiomyopathy or transient left apical ballooning syndrome (LABS) have been clearly described, but the mechanisms are still unknown. Our objective was to prospectively assess coronary microcirculation at the acute phase of LABS and after functional recovery, using Doppler transthoracic echocardiography-coronary flow reserve (CFR). Twelve consecutive patients (11 women, mean age 68 +/- 10 years) satisfying the criteria for LABS underwent Doppler transthoracic echocardiography-CFR in the distal part of the left anterior descending coronary artery, using intravenous adenosine infusion (0.14 mg/kg/min over 2 minutes) at the acute phase and 25 +/- 3 days later. CFR was calculated as the ratio of hyperemic to basal mean diastolic flow velocity. Wall-motion score (WMS) was calculated using the 16-segment model during the same echocardiographic examination (normal WMS = 16). Doppler transthoracic echocardiography-CFR increased between the two examinations from 2.2 +/- 0.4 at the acute phase to 2.9 +/- 0.3 (P < .01), whereas WMS decreased (from 31 +/- 6 at the acute phase to 16.5 +/- 0.8, delta WMS = -14.6 +/- 6, P < .01). All patients exhibited an increase of CFR between the two tests (delta CFR = 0.73 +/- 0.39, range: 0.3-1.6). A significant correlation was observed between delta CFR and delta WMS (r = -0.89, P < .01). In conclusion, serial noninvasive CFR measurements performed in LABS suggested transient microcirculatory impairment during the acute phase of the syndrome. The wall-motion improvement parallel to the dynamic improvement of the microcirculation suggests a role of coronary microcirculatory damage in the pathogenesis of acute and transient wall-motion abnormalities in LABS.

Toxicité myocardique des catécholamines : à propos de deux observations

Introduction The role of catecholamines in the cardiac expression of pheochromocytoma is well-known. The physiopathology of the syndrome of Tako-tsubo remains more unclear. Exegesis We describe 2 clinical cases of acute coronary syndrome with left ventricular dysfunction and no coronary artery stenosis. The first, a syndrome of Tako-tsubo, also known as transient left ventricular apical ballooning syndrome, is characterized by transient wall-motion in the absence of obstructive epicardial coronary disease. The second is a pheochromocytoma with myocardial suffering during hypertension crisis. Through the similarities of these 2 observations, we discuss the physiopathological assumptions to explain the syndrome of Tako-tsubo by underlining the essential place of the catecholamine hypersecretion. Conclusion Syndrome of Tako-tsubo and pheochromocytoma are 2 distinct clinical entities. The link between these 2 affections is probably the pathogenic role in cardiac toxicity with the catecholamines.

Síndrome Tako-Tsubo en una paciente con exacerbación de asma bronquial

Transient apical ballooning syndrome without coronary stenosis or Tako-Tsubo syndrome was described a few years ago in a Japanese population. Although new cases and series have been gradually defining its physiopathology, there is much doubt about its etiology. We describe the case of a 74-year-old Caucasian woman, with a background of hypertension, type 2 diabetes mellitus and hyperthyroidism with tracheal compression, intrinsic asthma and depression syndrome. She had an acute attack of bronchospasm and chest pain. The electrocardiogram on admission showed Q-waves and ST segment elevation in precordial leads and elevated serum cardiac markers. The coronariography found no evidence of significant lesions in the vascular tree. Ventriculography showed an apical ballooning that was also found in the echocardiography. The evolution of the clinical picture with disappearance of the symptoms and normalization of the electrocardiogram and echocardiogram lead to the diagnosis of Tako-Tsubo syndrome. We believe that this new clinical entity may have a catecholamine-mediated neurogenic mechanism as the etiopathogenic substrate and that our clinical case could support this hypothesis.

Takotsubo cardiomyopathy in a Caucasian Italian woman: Case report

BackgroundTakotsubo cardiomyopathy is an acute cardiac syndrome characterized by transient LV regional wall motion abnormalities (with peculiar apical ballooning appearance), chest pain or dyspnea, ST-segment elevation and minor elevations of cardiac enzyme levelsCase presentationA 68-year-old woman was admitted to the Emergency Department because of sudden onset chest pain occurred while transferring her daughter, who had earlier suffered a major seizure, to the hospital. The EKG showed sinus tachycardia with ST-segment elevation in leads V2–V3 and ST-segment depression in leads V5–V6, she was, thus, referred for emergency coronary angiography. A pre-procedural transthoracic echocardiogram revealed regional systolic dysfunction of the LV walls with hypokinesis of the mid-apical segments and hyperkinesis of the basal segments. Coronary angiography showed patent epicardial coronary arteries; LV angiography demonstrated the characteristic morphology of apical ballooning with hyperkinesis of the basal segments and hypokinesis of the mid-apical segments. The post-procedural course was uneventful; on day 5 after admission the echocardiogram revealed full recovery of apical and mid-ventricular regional wall-motion abnormalities.ConclusionTakotsubo cardiomyopathy is a relatively rare, unique entity that has only recently been widely appreciated. Acute stress has been indicated as a common trigger for the transient LV apical ballooning syndrome, especially in postmenopausal women. The present report is a typical example of stress-induced takotsubo cardiomyopathy in a Caucasian Italian postmenopausal woman.

Le syndrome de tako-tsubo : enjeu thérapeutique

The authors report the case of 2-old-caucasian women in the pre- and interhospital setting, who presented chest pain with ST segment elevation. Coronary angiography did not show any significant coronary lesion, ventriculography revealed typical aspect of tako-tsubo. It resolved in a short time, with normalisation of the left ventricule function. The tako-tsubo syndrome, or transient left ventricular apical ballooning syndrome, first described by Japanese physicians, is more and more frequently observed in caucasian patients. This cardiomyopathy associates an apical transient dysfunction without any significant coronary lesion. This syndrome is usually observed in elderly women, occurs frequently after acute emotional or physical stress. The clinical presentation looks like an acute coronary syndrome, with chest pain, electrocardiographic changes and moderate cardiac enzymes release. Coronary angiography shows no significant coronary disease and ventriculography a systolic dysfunction with akinesia of middle and apical segments, leading apical ballooning, and basale hyperkinesia. These abnormalities are transient, with quick favorable outcome. The aetiopathegenia is still uncertain. The differential diagnosis with an acute coronary syndrome with thrombosis is not yet possible. Clinical or biological criteria allowing early diagnosis would lead to optimize the therapeutic management.

Functional derangement and cardiac innervation in the apical ballooning syndrome: a 123I-meta-iodobenzylguanidine scintigraphic and dobutamine stress echocardiographic study

Several cases of transient left ventricular apical ballooning syndrome have already been described, but the pathophysiological mechanisms of this syndrome still remain unclear. We report the case of a patient evaluated in the acute phase of apical ballooning by coronary angiography and echocardiography who was submitted to I-meta-iodobenzylguanidine (MIBG) myocardial scintigraphy and dobutamine stress echocardiography one month after the discharge. MIBG scintigraphy demonstrated a decreased tracer uptake in the apical and periapical anterior regions, whilst myocardial perfusion at rest was normal. Dobutamine induced an increased left ventricular outflow tract gradient and hypokinesis in the apical and periapical segments, mimicking the findings that occurred in the acute phase, and in agreement with the location of MIBG abnormalities. After a two-month treatment with carvedilol, MIBG uptake increased in the apical and periapical anterior regions.

Mid‐Ventricular Ballooning Heart Syndrome

Stress cardiomyopathies have been increasingly reported these last years, especially in women as a transient left ventricular apical ballooning syndrome. We report six cases in whom, in the context of anxious situations, echocardiograms and ventriculographies revealed mid-ventricular akinesis with preservation of apical and basal contractilities with normal coronary arteriography. This "mid-ventricular ballooning heart syndrome " should probably be classified as a new type of heart stress related syndrome.

Assessment of coronary flow reserve by transthoracic Doppler echocardiography in left apical ballooning syndrome

We present the time course of transthoracic coronary flow reserve in the left anterior descending artery in a patient who suffered a transient left apical ballooning syndrome.

Apical ballooning syndrome complicated by acute severe mitral regurgitation with left ventricular outflow obstruction – Case report

BackgroundApical ballooning syndrome (or Takotsubo cardiomyopathy) is a syndrome of transient left ventricular apical ballooning. Although first described in Japanese patients, it is now well reported in the Caucasian population. The syndrome mimicks an acute myocardial infarction but is characterised by the absence of obstructive coronary disease. We describe a serious and poorly understood complication of Takotsubo cardiomyopathy.Case PresentationWe present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. It was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect.Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60–70 mmHg). Coronary angiography revealed no obstructive coronary lesions.She had an intra-aortic balloon pump inserted with no improvement in her parlous haemodynamic state. We elected to replace her mitral valve to correct the outflow tract gradient and mitral regurgitation. Intra-operatively the mitral valve was mildly myxomatous but there were no structural abnormalities. She had a mechanical mitral valve replacement with a 29 mm St Jude valve. Post-operatively, her left ventricular outflow obstruction resolved and ventricular function returned to normal over the subsequent 10 days. She recovered well.ConclusionThis case represents a serious and poorly understood association of Takotsubo cardiomyopathy with acute pulmonary oedema, severe mitral regurgitaton and systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction. The sequence of our patient's presentation suggests that the apical ballooning caused geometric alterations in her left ventricle that in turn led to acute and severe mitral regurgitation, systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction. The left ventricular outflow tract obstruction and mitral regurgitation were corrected by mechanical mitral valve replacement. We describe a variant of Takotsubo cardiomyopathy with acute mitral regurgitation, systolic anterior motion of the mitral valve leaflet and left ventricular outflow tract obstruction of a dynamic nature.

Transient left ventricular apical ballooning syndrome (takotsubo cardiomyopathy) as a complication of permanent pacemaker implantation

Background Takotsubo cardiomyopathy is a rare and newly described clinical entity characterized by transient left ventricular apical ballooning and left ventricular apical dyskinesis in the absence of angiographic evidence of significant coronary vessel disease found predominantly in post-menopausal women. It was first documented in the USA in 2004, and it has previously been described only in Japanese and Caucasian patients. Case report A 77-year-old Native Hawaiian woman was admitted to the hospital for severe bradycardia. To the best of our knowledge, this is the first time that normal ventricular function has been documented by echocardiography just prior to the development of the syndrome of transient left ventricular apical ballooning. Methods Retrospective review of the reported patient's medical record, cardiac angiography and ventriculography, echocardiography, and ECGs. Discussion The patient reported manifested all of the diagnostic criteria for transient left ventricular apical ballooning syndrome proposed by the Mayo Clinic. The finding of normal cardiac morphology and contractility by echocardiography two days prior to diagnosis shows that this syndrome develops rapidly. The case reported here is the first time that transient left ventricular apical ballooning syndrome has been documented in a Native Hawaiian patient in a tropical location, suggesting that transient left ventricular apical ballooning likely occurs across all ethnic and geographical lines.

Apical Ballooning Syndrome

Case presentation: A 60-year-old woman presented to the emergency department 2 hours after the onset of severe retrosternal chest pain that started soon after she was told that her son had died in a car accident. A 12-lead ECG demonstrated ST-elevation in the precordial leads (Figure 1), and the plasma troponin T level was elevated at 0.07 ng/mL. A diagnosis of acute ST-elevation myocardial infarction was made, and the patient was admitted for emergency coronary angiography, which revealed normal coronary arteries. The left ventriculogram showed severe systolic dysfunction involving the mid and apical segments (Data Supplement Movie I). Figure 1. Twelve-lead ECG demonstrating ST-segment elevation in precordial leads. Physicians have long been aware of the possible association between stress and cardiovascular events. Awareness has increased of a distinct cardiac syndrome that was originally described in the Japanese population and was called Takotsubo cardiomyopathy, named after the octopus-trapping pot with a round bottom and narrow neck that resembles the left ventriculogram during systole in these patients.1,2 Other names used to describe the condition include apical ballooning syndrome (ABS), broken heart syndrome, and stress or ampulla cardiomyopathy. The precise incidence of ABS is unknown, but it may account for 1% to 2% of patients who present with an acute myocardial infarction.3 The majority of patients have a clinical presentation that is indistinguishable from an acute coronary syndrome. Most present with chest pain at rest, although some patients have dyspnea alone as their initial presenting symptom. Rarely, patients present with syncope or an out-of-hospital cardiac arrest.4 ABS appears to occur almost exclusively in postmenopausal women; however, a few cases have been reported in younger women and males.4 The patients are usually hemodynamically stable, but clinical findings of mild-to-moderate congestive heart failure …

Apical ballooning syndrome, emotional stress and women

In their systematic review, Gianni et al. 1 described clinical characteristics of the transient left-ventricular apical ballooning syndrome or takotsubo cardiomyopathy. They found that the disease onset is preceded by emotional stress in 26.8% and physical stress in 37.8% of cases. However, two largest and most comprehensive studies in western populations strongly have pointed toward the striking female predominance, but also toward the importance of emotional stress as a possible external triggering event, observed in 86 and 100% of cases.2,3 In addition, …

Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction

Objective The presentation and electrocardiographic (ECG) characteristics of transient left ventricular apical ballooning syndrome (TLVABS) can be similar to that of anterior ST-segment elevation myocardial infarction (STEMI). We tested the hypothesis that the ECG on presentation could reliably differentiate these syndromes. Subjects and Methods Between January 1, 2002 and July 31, 2004, we identified 18 consecutive patients with TLVABS who were matched with 36 subjects presenting with acute anterior STEMI due to atherothrombotic left anterior descending coronary artery occlusion. Results All patients with TLVABS were women (mean age, 72.0 ± 13.1 years). The heart rate, PR interval, QRS duration, and corrected QT interval were similar between groups. Distribution of ST elevation was similar, but patients with anterior STEMI exhibited greater ST elevation. Regressive partitioning analysis indicated that the combination of ST elevation in lead V 2 of less than 1.75 mm and ST-segment elevation in lead V 3 of less than 2.5 mm was a suggestive predictor of TLVABS (sensitivity, 67%; specificity, 94%). Conditional logistic regression indicated that the formula: (3 × ST-elevation lead V 2) + (ST-elevation V 3) + (2 × ST-elevation V 5) allowed possible discrimination between TLVABS and anterior STEMI with an optimal cutoff level of less than 11.5 mm for TLVABS (sensitivity, 94%; specificity, 72%). Patients with TLVABS were less likely to have concurrent ST-segment depression (6% vs 44%; P = .003). Conclusions Women presenting with TLVABS have similar ECG findings to patients with anterior infarct but with less-prominent ST-segment elevation in the anterior precordial ECG leads. These ECG findings are relatively subtle and do not have sufficient predictive value to allow reliable emergency differentiation of these syndromes.

Transient left ventricular apical ballooning syndrome following a hyponatraemic seizure

Transient left ventricular apical ballooning syndrome (TLVABS) was initially described in Japan in the early 1990's [ [1] Satoh H. Tateishi H. Uchida T. Takotsubo –type cardiomyopathy due to multivessel spasm. in: Kodama K. Haze K. Hon M. Clinical Aspect of Myocardial Injury: from Iscemia to Heart Failure (in Japanese). Kagakuhyouronsya Co., Tokyo1990: 56-64 Google Scholar ] and was called Takotsubo-type cardiomyopathy. Tako-tsubo is Japanese for octopus pot or trap, which resembles the left ventricular apical ballooning seen with this condition. This disorder is characterized by chest pain, anterior ST segment elevation, reversible left ventricular apical dyskinesis, minimal cardiac enzyme rise and smooth ‘normal’ coronary arteries [ [2] Tsuchihashi K. Ueshima K. Uchida T. et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol. 2001; 38: 11-18 Abstract Full Text Full Text PDF PubMed Scopus (1346) Google Scholar ].

Two Cases of Transient Left Ventricular Apical Ballooning Syndrome Associated with Subarachnoid Hemorrhage

Electrocardiogram (ECG) abnormalities secondary to subarachnoid hemorrhage are well known, but the etiology remains unclear. Transient left ventricular apical ballooning syndrome is characterized by acute onset myocardial infarction-like symptoms, transient (reversible) cardiac dysfunction, and shapes resembling ampulla on left ventriculography. We managed general anesthesia for two patients with transient left ventricular apical ballooning and ECG abnormalities associated with subarachnoid hemorrhage. During anesthesia, their hemodynamic status was almost stable although their cardiac performance analyzed by transthoracic echocardiography and transesophageal cardiography was poor. Anesthetic management of this syndrome may be simplified if less cardiosuppressive anesthetic management is used. We recommend evaluating cardiac function with transthoracic echocardiography or transesophageal cardiography when an subarachnoid hemorrhage patient has ECG abnormalities.

Early Postoperative Tako-Tsubo-Like Left Ventricular Dysfunction: Transient Left Ventricular Apical Ballooning Syndrome

We diagnosed transient left ventricular apical wall motion abnormalities after surgery in a patient presenting with a clinical and electrocardiographic picture of acute myocardial infarction in the absence of significant coronary disease. These angiographic, clinical, and electrocardiographic features satisfied the criteria of the recently described tako-tsubo-like left ventricular dysfunction.

Syndrome de ballonisation apicale transitoire du ventricule gauche. Revue de la littérature à propos d'un cas

Subject Transient left ventricular apical ballooning syndrome, knowed as the japanese name of tako-tsubo was recently described and is characterised at the acute period by a large apical dyskinesia of the left ventricule apex. This syndrome usually mimick an acutre coronary syndrome, sometime a cardiac faillure or arrhythmias. We report a typical case of a seventy-seven years old women struck by a tako-tsubo syndrome revelated by an acute chest pain after an emotional stress. The diagnosis was proposed because angiographie didn't shown any abnormality in spite of a large left ventricular dysfunction at the ventriculography. Topicality Tako-tsubo syndrome is more and more published due to a better knowledge of this syndrome, specially in the acute coronary syndrome without coronary abnormality. His physiopatology is not well known but is clearly in relation with an acute stress. Several hypothesis are discussed, helped by some experimental animal model. With an excellent prognosis at a middle-course, his discovery allow an adapted take care especialy of the complications. Prospect The setting up of clinical and electrocardological reliable and well-tried criteria will allowed an early diagnosis to avoid harmful treatment. His specific treatment is not reached by consensus but will develop by a better knownledge of the physiopathology.

Transient Midventricular Ballooning Syndrome: A New Variant

We describe a new variant of transient left ventricular (LV) ballooning in North American Caucasian patients in which only the midventricle is affected. The patients described in this case series initially presented with emotional or physical stress and had similarities to transient apical ballooning syndrome; however, this variant is unique in that the transient ballooning involves the midventricle with hypercontractility of the apical and basal segments. The presentation, clinical features, and transient nature of the reported cases in this series are similar to transient LV apical ballooning and suggest a shared pathophysiologic etiology. Sparing of the apical segment with involvement of midventricle only supports etiologies not related to an epicardial coronary artery distribution. Although the pathophysiologic mechanism of the transient ventricular ballooning syndromes and other cases of catecholamine-associated transient ventricular dysfunction are not well understood, the emergence of this new variant raises further questions in the understanding of the "brain-heart" relationship.

Transient Left Ventricular Apical Ballooning Syndrome

A 63-year-old woman with a history of hypertension and paroxysmal supraventricular tachycardia presented with substernal chest pain that extended to her back and was associated with profound weakness and shortness of breath. Physical examination revealed an anxious-appearing woman with tachycardia (pulse rate, 123 beats/min) and hypertension (blood pressure, 180/95 mm Hg). Electrocardiography showed ST-segment elevation in leads V 2 through V 6 . The troponin T level was 0.32 ng/mL (reference range, <0.03 ng/mL), and the creatine kinase-MB fraction was 8.2 ng/mL (reference range, <6.2 ng/mL). Probable STsegment elevation myocardial infarction was diagnosed, and emergent cardiac catheterization was performed. Coronary angiography showed only mild atherosclerosis. However, left ventriculography revealed an ejection fraction of 34% with moderate hypokinesis of the apical segments suggestive of transient left ventricular apical ballooning syndrome. Also known as Takotsubo cardiomyopathy, after a round-bottomed narrow-necked Japanese fishing pot used for trapping octopus, transient left ventricular apical ballooning syndrome was first described in Japan by Dote et al more than a decade ago. It is characterized by transient For editorial comment, see page 732 left apical and midventricular wall motion abnormalities in the absence of acute occlusive coronary artery disease. The disorder occurs most commonly in postmenopausal women, who present with symptoms, electrocardiographic changes, and mildly elevated cardiac enzymes suggestive of acute ST-segment elevation myocardial infarction. Although the exact cause of the syndrome is unknown, episodes are often preceded by an acute increase in psychologic or emotional stress. Treatment includes monitoring and supportive care, and the overall prognosis is favorable.