Transient Left Ventricular Apical Ballooning Research Articles

Takotsubo Cardiomyopathy and Autoimmune Disorders: A Systematic Scoping Review of Published Cases.

Takotsubo cardiomyopathy (TCM) features transient left ventricular apical dysfunction or ballooning. The underlying mechanism remains elusive; however, evidence suggests the role of different physical and psychological stressors. We systematically reviewed patients presenting with TCM and autoimmunity to explore the link between the two conditions. We applied the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) to report this review. Using keywords related to autoimmune/immune-mediated diseases and TCM, we searched PubMed, Scopus, and WOS in March 2022. The final results were added to a data extraction sheet. Data were analyzed by SPSS version 26.0. Our search yielded 121 studies, including 155 patients. Females were considerably predominant. Most patients had a history of autoimmune disease, and almost a third had a history of cardiovascular disease. Dyspnea and chest pain were the most common chief complaints. More than 70% of patients had experienced physical stress. Myasthenia gravis, systemic lupus erythematosus, and multiple sclerosis were the most frequently reported autoimmune diseases. There were similarities in age and sex compared to classic TCM. TCM should be considered as a differential diagnosis for ACS, especially in patients with a positive background of autoimmunity. A precise reporting system is required for further studies.

Upregulation of neuropeptide Y in cardiac sympathetic nerves induces stress (Takotsubo) cardiomyopathy.

Substantial emotional or physical stress may lead to an imbalance in the brain, resulting in stress cardiomyopathy (SC) and transient left ventricular (LV) apical ballooning. Even though these conditions are severe, their precise underlying mechanisms remain unclear. Appropriate animal models are needed to elucidate the precise mechanisms. In this study, we established a new animal model of epilepsy-induced SC. The SC model showed an increased expression of the acute phase reaction protein, c-Fos, in the paraventricular hypothalamic nucleus (PVN), which is the sympathetic nerve center of the brain. Furthermore, we observed a significant upregulation of neuropeptide Y (NPY) expression in the left stellate ganglion (SG) and cardiac sympathetic nerves. NPY showed neither positive nor negative inotropic and chronotropic effects. On the contrary, NPY could interrupt β-adrenergic signaling in cardiomyocytes when exposure to NPY precedes exposure to noradrenaline. Moreover, its elimination in the left SG via siRNA treatment tended to reduce the incidence of SC. Thus, our results indicated that upstream sympathetic activation induced significant upregulation of NPY in the left SG and cardiac sympathetic nerves, resulting in cardiac dysfunctions like SC.

The Impact of Mental Stress on Cardiovascular Health-Part II.

Endothelial dysfunction is one of the earliest manifestations of atherosclerosis, contributing to its development and progression. Mental stress induces endothelial dysfunction through increased activity of the sympathetic nervous system, release of corticotropin-releasing hormone from the hypothalamus, inhibition of nitric oxide (NO) synthesis by cortisol, and increased levels of pro-inflammatory cytokines. Mental-stress-induced increased output of the sympathetic nervous system and concomitant withdrawal of the parasympathetic inflammatory reflex results in systemic inflammation and activation of a neural–hematopoietic–arterial axis. This includes the brainstem and subcortical regions network, bone marrow activation, release of leukocytes into the circulation and their migration to the arterial wall and atherosclerotic plaques. Low-grade, sterile inflammation is involved in all steps of atherogenesis, from coronary plaque formation to destabilisation and rupture. Increased sympathetic tone may cause arterial smooth-muscle-cell proliferation, resulting in vascular hypertrophy, thus contributing to the development of hypertension. Emotional events also cause instability of cardiac repolarisation due to brain lateralised imbalance of cardiac autonomic nervous stimulation, which may lead to asymmetric repolarisation and arrhythmia. Acute emotional stress can also provoke severe catecholamine release, leading to direct myocyte injury due to calcium overload, known as myocytolysis, coronary microvascular vasoconstriction, and an increase in left ventricular afterload. These changes can trigger a heart failure syndrome mimicking acute myocardial infarction, characterised by transient left ventricular dysfunction and apical ballooning, known as stress (Takotsubo) cardiomyopathy. Women are more prone than men to develop mental-stress-induced myocardial ischemia (MSIMI), probably reflecting gender differences in brain activation patterns during mental stress. Although guidelines on CV prevention recognise psychosocial factors as risk modifiers to improve risk prediction and decision making, the evidence that their assessment and treatment will prevent CAD needs further evaluation.

Takotsubo cardiomyopathy in a bedridden patient with dementia and communication difficulties due to Alzheimer's disease.

Takotsubo cardiomyopathy is a transient wall motion abnormality of the left ventricular apex, accompanied by emotional or physical stress. Although Takotsubo cardiomyopathy is generally considered a benign disease, severe clinical complications may occur, and early detection of the disease is important. In this report, we present the case of an 86-year-old bedridden woman with a history of bronchial asthma who was transferred to our hospital because of wheezing. She was diagnosed with Alzheimer’s disease and had communication difficulties. After an asthma attack and improvement, Takotsubo cardiomyopathy was identified via electrocardiography. She was unable to complain of any symptoms but showed serial electrocardiographic changes, elevated myocardial markers, and transient left ventricular apical ballooning. The prevalence of dementia increases dramatically with age. This case indicates that Takotsubo cardiomyopathy may occur even in patients with severe dementia, who are bedridden and show communication difficulties in a clinical setting.

Zumba-induced Takotsubo cardiomyopathy: a case report

BackgroundTakotsubo cardiomyopathy or stress cardiomyopathy is characterized by transient left ventricular apical ballooning in the absence of coronary occlusion. The underlying pathophysiological mechanism is still unclear but possible causes have been proposed mainly catecholamine cardiotoxicity, followed by metabolic disturbance, coronary microvascular impairment, and multivessel epicardial coronary artery vasospasm. Takotsubo cardiomyopathy accounts for 1–2% of patients presenting with acute coronary syndrome with the majority of patients diagnosed with Takotsubo cardiomyopathy being women > 55 years of age. Here, we discuss the case of a 38-year-old woman presenting with typical chest pain, electrocardiography changes and cardiac markers consistent with acute coronary syndrome, who was subsequently diagnosed with Takotsubo cardiomyopathy.Case presentationA 38-year-old healthy American woman with negative past medical history presented to our Emergency Department with chest pain developing while participating in intense outdoor physical activities (Zumba) at a fundraising event. Our patient had typical substernal chest pain induced with exercise and was relieved by sublingual nitroglycerin in the Emergency Department. The pain started after 2 h of intensive Zumba workout. On review of her history, our patient was noted to be taking spironolactone 125 mg once daily for hirsutism for the past year. Our patient denied any family history of cardiac disease or heart failure. She admitted to being a former occasional smoker and to drinking alcohol socially. She denied any illicit drug use. She works as a social worker, and reported that she does not experience much stress in her life and denied any “one big life-changing event” or any major stressful news. While in the Emergency Department, our patient was hemodynamically stable and an electrocardiography was performed and showed sinus rhythm with no ST elevation/depression but noted T-wave inversion in leads I and aVL, and T wave flattening in leads V1 and V2. Her troponin levels were 0.294 and 0.231 consecutively. An echocardiogram was done and showed hypokinetic apical and mid-distal walls and hyperdynamic basal walls of the left ventricle with an ejection fraction of 35–40%, consistent with apical ballooning syndrome. Cardiac catheterization was subsequently done and showed depressed left ventricle systolic function, ejection fraction of 30–35% with anteroapical dyskinesia and no evidence of coronary artery disease.Our patient was diagnosed with Takotsubo cardiomyopathy after fulfilling all four of the Mayo Clinic’s diagnostic criteria and was subsequently treated with a beta blocker, and angiotensin-converting enzyme inhibitor.ConclusionsOur patient did not have one clear trigger for her overt Takotsubo cardiomyopathy other than the Zumba activity. Zumba is considered an activity with excessive sympathetic stimulation leading to catecholamine-induced microvascular spasm or through to direct myocardial toxicity, which is postulated to be behind the pathophysiology of Takotsubo cardiomyopathy. Another interesting finding in our patient was her use of spironolactone, as treatment for hirsutism, which is an aldosterone antagonist. Aldosterone actually potentiates the effects of catecholamine and thus activates the sympathetic system. Spironolactone can thus be considered as cardioprotective against the effects of catecholamine on the heart and that is why it is considered to be beneficial and subsequently improves mortality in chronic heart failure as described in several studies.

The ATAK complex (Adrenaline, Takotsubo, Anaphylaxis, and Kounis hypersensitivity -associated coronary syndrome) in neurological conditions.

Sir, Takotsubo syndrome, transient left ventricular apical ballooning, takotsubo cardiomyopathy, apical ballooning syndrome, atypical apical ballooning, ampulla cardiomyopathy, broken heart syndrome, transient left ventricular dysfunction syndrome, and stress cardiomyopathy were named after a round-bottomed and narrow-necked fishing pot - takotsubo in Japanese - for trapping octopus because of its resemblance to left ventriculogram. In the interesting report published in Indian Journal of Critical Care Medicine,[1] a 48-year-old man with progressive loss of vision, hypotension, tachycardia, and acidosis was found to have takotsubo syndrome while the coronary arteries were normal. Computerized tomography revealed dense sellar-suprasellar mass lesion extending into the hypothalamus resembling pituitary adenoma with hypocortisolism suggesting hypopituitarism. With dobutamine, atenolol, and noradrenaline, his condition improved. This case raises some issues concerning neurological conditions, mental stress adrenaline, anaphylaxis, and Kounis syndrome. Mental stress commences with impulses from high brain cortical centers that are relayed through the limbic system to hypothalamus resulting in the release of corticotropin-releasing hormone (main coordinator of the mental stress response) and norepinephrine, serotonin, acetylcholine, proopiomelanocortin, adrenocorticotropic hormone, glucagon, growth hormone, and homocysteine that stimulate sympathetic nervous system. These substances can induce heightened cardiovascular activity, endothelial injury, induction of adhesion molecules on the endothelial cells, to which recruited inflammatory cells adhere and translocate to the arterial wall and finally myocardial damage. An acute phase response is engendered, resulting in production of cytokines interleukin-1 (IL-1), IL-6, tumor necrosis factor-alpha, acute phase proteins, macrophage, mast cell, and platelet activation that eventually culminate in the development of Kounis syndrome.[2] Stress-induced cytokine production has been incriminated for multivessel coronary artery spasm at epicardial or microvascular levels that induce takotsubo cardiomyopathy. Inflammatory mediators released during anaphylaxis can induce coronary spasm and takotsubo syndrome and adrenaline given for anaphylaxis might contribute to coronary spasm and transient takotsubo syndrome. Adrenaline and noradrenaline released by the renin-angiotensin-aldosterone system together with histamine stimulate the release of more catecholamines by direct action on the adrenal medullary cells. Administration of catecholamines for hemodynamic support of anaphylactic shock would also increase the plasma catecholamines. Catecholamine increase in patients with angina, renders blood platelets more sensitive and more prone to aggregation and thrombosis. Therefore, measurement of anaphylactic inflammatory mediators including histamine, chymase, leukotrienes, thromboxane, and platelet activating factor or the use of corticosteroids or mast cell stabilizers for prevention and treatment may shed light on etiology and pathophysiology of takotsubo cardiomyopathy. The concurrence of acute coronary syndromes with conditions associated with mast cell activation, involving interrelated and interacting inflammatory cells constitute the Kounis syndrome.[3] Inflammatory cells, such as mast cells, T-cells, and macrophages, activate each other via multidirectional stimuli and release mediators capable to induce coronary events. Experimental findings suggest that cardiac mast cell activation by acute stress may contribute to myocardial ischemia through the release of histamine or proinflammatory mediators.[4] Therefore, takotsubo cardiomyopathy should be always considered in neurological conditions with prolonged addisonian crisis. Furthermore, Adrenaline, takotsubo, Anaphylaxis, and Kounis syndrome (ATAK) seem to constitute a challenging contemporary complex that needs inexorable “attack” to elucidate its etiology, pathophysiology, and treatment.[5] Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest

Attack the ATAK : “οὓς ὁ θεὸς συνέζευξε, ἄνθρωπος μὴ χωριζέτω” (ous o theos synezeuxe anthropos me horizeto) “what therefore God hath joined together, let not man put asunder”

“Voodoo Death”was the title of a paper published, more than half a century ago [1], by the renowned American physiologist Walter B. Cannon and was based on anecdotal experiences, largely from the anthropology literature, dealing with death from fright. “Voodoo” is of African origin and concerns superstitious beliefs and practices found among Negroes of West Indies and Southern United States. Canon was the first to postulate that death from fright is caused by a lasting and intense action of sympathico-adrenal system. Phrases such as “scared to death” and “a broken heart”, are still used today and are deeply rooted in folk wisdom and reflect potentially lethal consequences of emotional, depressogenic or mental stress. Indeed, terms such as broken heart syndrome, transient left ventricular apical ballooning, stress-induced cardiomyopathy, apical ballooning syndrome, atypical apical ballooning, ampulla cardiomyopathy or transient left ventricular dysfunction syndrome characterize the takotsubo syndrome that usually follows emotional distress. This clinical entity has been excessively discussed nowadays but there are many questions regarding its etiology, pathophysiology and treatment which still remain unanswered. It has been emphasized recently [2] that adrenaline, takotsubo, anaphylaxis, and Kounis syndrome (ATAK) constitute a challenging contemporary complex that needs “attacking” in order to elucidate its etiology and pathophysiology and apply the proper preventive and therapeutic measures.

Ischemic changes in electrocardiography (ECG) after attempted suicide by hanging (transient left ventricular apical ballooning)

The Sri Lankan Journal of Anaesthesiology is the official journal of the College of Anaesthesiologists of Sri Lanka. It publishes clinical investigations, research articles, audits, case reports, review articles and CME articles relating to anaesthesiology, critical care and pain. It is published bi annually in January and June. Sri Lankan Journal of Anaesthesiology is included on DOAJ and Scopus.

Síndrome de discinesia apical transitoria durante ecocardiografía de estrés con dobutamina

The transient left ventricular apical ballooning syndrome, also known as Tako-Tusbo syndrome, has an acute onset, is more common in postmenopausal women, and is characterized by transient left ventricular apical ballooning, chest pain, electrocardiographic abnormalities, and slight elevation of markers for myocardial injury, mimicking a myocardial infarction in patients with no significant coronary lesions. However, before making the diagnosis, other causes of reversible left ventricular dysfunction must be ruled out, such as subarachnoid hemorrhage, pheochromocytoma crisis, acute myocarditis, or the presence of tachycardiomyopathy. The case is presented of a patient who developed ST elevation electrocardiographic changes with apical transient dyskinesia during dobutamine stress echocardiography.

Long QT-induced ventricular tachycardia associated with Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is a syndrome characterized by transient left ventricular apical ballooning associated with electrocardiogram changes and mimicking acute myocardial infarction in patients without significant coronary disease on angiography. We report an unusual case of a patient who presented with TC associated with long-QT syndrome-induced ventricular tachycardia. QT interval prolongation was normalized and ventricular tachycardias were stopped within the same day with metoprolol treatment.

Usefulness of myocardial positron emission tomography/nuclear imaging in Takotsubo cardiomyopathy.

To analyse and summarize all the articles related to positron emission tomography and Takotsubo cardiomyopathy (TTC). We performed a systematic review of the existing literature on positron emission tomography/nuclear imaging and Takotsubo cardiomyopathy using PUBMED database. We combined search terms such as "takotsubo", "takotsubo syndrome", "myocardial positron emission tomography", "positron emission tomography". All case reports were excluded. The list included only four articles which were reviewed by two independent investigators. It was not possible to undertake a formal meta-analysis because of the heterogeneity of the studies; therefore, we made a narrative synthesis of the collected data. Nuclear medicine techniques can be useful employed in the differential diagnosis of TTC from an acute coronary syndrome (ACS). In fact, transient left ventricular (LV) apical ballooning is a syndrome frequently misdiagnosed as an ACS and can mimic symptoms of myocardial infarction with ST-T segments changes on electrocardiography (ECG), a limited release of myocardial enzyme, mainly reported after sudden emotional or physical stress, and an akinesis or dyskinesis of the left ventricle apex which are completely reversible in a few weeks. In the studies included in this review, nuclear medicine techniques have demonstrated a discrepancy between normal perfusion and a reduced glucose utilization in TTC, commonly known as "inverse flow metabolism mismatch". This suggests that apical ballooning represents a transient metabolic disorder on the cellular level, rather than a structural contractile disease of the myocardium, due to a transient decrease of glucose metabolism that might be related to a coronary microcirculation impairment followed by prolonged myocardial stunning. Nuclear medicine techniques can be usefully used for the diagnosis of TTC and can increase our knowledge of the pathophysiological mechanisms of TTC.

24 Hour ST Segment Analysis in Transient Left Ventricular Apical Ballooning

ObjectiveThe etiologic basis of transient left ventricular apical ballooning, a novel cardiac syndrome, is not clear. Among the proposed pathomechanisms is coronary vasospasm. Long-term ST segment analysis may detect vasospastic episodes but has not been reported.Methods30 consecutive patients with transient left ventricular apical ballooning, left ventricular dysfunction and normal or near-normal coronary arteries were investigated. A 24-hour Holter ECG was obtained after emergency admission. ST segment analysis was performed automatically in 2 leads and confirmed by visual inspection. Criteria for an ischemic event were: 1. ST elevation or 2. horizontal or down-sloping ST segments ≥1 min duration and ≥100 µV J+80 point deviation corrected for baseline ST-deviation.ResultsPatients presented with ST segment elevation (n = 19) and/or T wave inversion (n = 20) on admission ECG. Ejection fraction was 50±12%. No transient ST elevations were observed during Holter ECG analysis. In 3 patients, 8 transient episodes of ST depression were recorded. Durations of episodes varied between 75s and 790s (mean 229s). Maximal ST deviation averaged −191±71 µV. Ischemic burden was −1 to −22 mVs (mean −8 mVs). 27 patients showed no ischemic events.ConclusionsST segment analysis of 24 h Holter recordings revealed minor ischemic events in only 10% of patients with transient left ventricular apical ballooning. Overall, ST segment changes were not indicative of recurrent coronary spasm playing a major role in the genesis of transient left ventricular apical ballooning.

Variable Morphology of Stress-Induced Cardiomyopathy

Variable Morphology of Stress-Induced Cardiomyopathy

Transient Left Ventricular Apical Ballooning in a Postmenopausal Woman with Chronic Liver Disease, Malignancy, and Recent Ischemic Stroke: A Case Report and Review of the Literature

Transient left ventricular apical ballooning (TLVAB), or Takotsubo cardiomyopathy, is a poorly understood phenomenon that is thought to be related to a surge of catecholamines under stress conditions that causes microvascular dysfunction and a unique pattern of myocardial stunning. TLVAB occurs in two distinct patient populations: (i) community presentation similar to acute coronary syndrome and (ii) the critically ill. Understanding the differences in presentation, prognosis and management between these two groups may improve the outcome. We present a case of TLVAB developing in a Caucasian postmenopausal female who developed TLVAB suddenly on a background of chronic liver disease, malignancy, and recent ischemic stroke. The patient presented with hemodynamic collapse and was treated with inotropes, vasopressors, and supportive care until cardiac function improved. Additionally, we review the current literature describing the risk factors, pathophysiology, and treatment of TLVAB.

Stress-Induced Cardiomyopathy Presenting as Ventricular Tachycardia

Stress-Induced Cardiomyopathy Presenting as Ventricular Tachycardia

Takotsubo cardiomyopathy in a patient with lung adenocarcinoma

Takotsubo cardiomyopathy (TC) is a rare and usually physical or emotional stress-induced clinical disorder characterized by transient left ventricular dysfunction and apical segment ballooning. Much is still unknown regarding risk factors and clinical relationships. Recently, an association between TC and malignancies has been proposed. We present a case of lung adenocarcinoma whose initial hospital admission was due to TC. We contribute this case report to the growing set of literature on the association between TC and malignancies.

Takotsubo Cardiomyopathy in an Elderly Patient With Severe Alzheimer's Disease: A Case Report

We report on an 80-year-old woman with Alzheimer's disease who presented with Takotsubo cardiomyopathy. As usual for this condition, our patient showed clinical symptoms of chest pain, electrocardiographic changes, elevated myocardial markers, and transient left ventricular apical ballooning in the absence of significant coronary artery disease. Because Takotsubo cardiomyopathy is frequently associated with emotional stress, which triggers an increase in circulating catecholamines, our case suggests that this event should not be neglected in Alzheimer's disease patients and promotes the adoption of a "prosthetic" approach for individuals with dementia.

Takotsubo Syndrome After Mitral Valve Replacement for Acute Endocarditis

Takotsubo syndrome is characterized by transient and acute left ventricular dysfunction and apical ballooning, with electrocardiographic abnormalities, but without coronary disease. We report a case of Takotsubo syndrome occurring after emergent mitral valve replacement for acute infective endocarditis. The patient is a 66-year-old woman who regained complete recovery of left ventricular function.

Przemijające zaburzenia kurczliwości koniuszka lewej komory u pacjenta z nadpłytkowością samoistną

Tako-tsubo syndrome imitates acute myocardial infarction. In this article, we report a case of a 39-year-old male who presented with essential thrombocythemia and symptoms and signs of acute coronary syndrome. On the basis of clinical features and results of additional tests we recognized transient left ventricular apical ballooning.

Partial status epilepticus causing a transient left ventricular apical ballooning

Transient left ventricular apical ballooning also called Takotsubo cardiomyopathy is a recently described cardiac syndrome. It often affects postmenopausal women having an acute physical or emotional stress, but it have also been described after convulsive status epilepticus. Although this association is rare and left ventricular function often recovers, it would be useful to the neurologist to be aware of the signs leading to this diagnosis, to improve the cardiac later care. Here we report a patient with partial status epilepticus in whom the diagnosis of transient left ventricular apical ballooning was made. We describe the diagnostic criteria and the potential complications that should be monitored.