Transient Left Ventricular Dysfunction Research Articles

992 EVALUATION OF MYOCARDIAL WORK INDEX IN PREDICTING IN-HOSPITAL COMPLICATION IN PATIENTS WITH TAKOTSUBO SYNDROME

Abstract Backgrounds Tako-tsubo syndrome (TTS) is a reversible heart failure pathology characterized by transient myocardial left ventricular (LV) dysfunction. Although traditionally considered a benign condition in-hospital complications are frequent in this cohort. Non-invasive myocardial work (MW) parameters are considered as emerging indexes in evaluating global and regional myocardial systolic function. Objective to investigate the potential association of MW compared to standard echocardiography parameters, such as LV ejection fraction (EF) with in-hospital complications, in TTS patients. Methods thirty-eight patients (mean age, 68 ± 12 years, 35 women) with TTS diagnosed with Takotsubo Italian Network criteria were prospectively enrolled and underwent a transthoracic Doppler echocardiography within 24 hours from hospital admission. MW is derived from the non-invasive strain-pressure loop obtained from the 2D strain data, integrating into its calculation the non-invasive brachial arterial pressure. Constructive MW (CMW), MW index (MWI), MW efficiency (MWE), and wasted myocardial work (WMW) were measured. In hospital complications (HC) were defined as a composite of apical LV thrombosis, hypokinetic arrhythmias (HA), supraventricular tachycardia (SVT), acute heart failure (AHF), ventricular tachycardia/fibrillation (VT/VF), cardiogenic shock (CS), respiratory arrest (RA), stroke and cardiac death (CD). The normal values ​​for the echocardiographic parameters are reported in the Table. Odds ratio, sensitivity and specificity were used to quantify the ability of EF and MW (abnormal vs normal values) in predicting HC. Results HC occurred in 16 TTS patients (26% with AHF; 10% with SVT; 8% with CS; 5% with apical LV thrombosis; 5% with HA; 2,6% with RA; 2,6% with stroke; 2% with VT/VF). The MWI and CMW parameters appear to have the best performance in predicting in-hospital complications (odds ratio for having HC: 10.4 (95% confidence interval: 1.2 to 93.3); 8.6 (0.9 to 77.6) respectively, Table), followed by EF (odds ratio 7.0 (0.8 to 64.1)) and WMW (odds ratio 4.8 (0.9 to 26.7)). MWI has the same sensitivity (94%) as CMW and EF, but higher specificity (41% vs 32%). Of note, the highest specificity was obtained by the WMW parameter (41%). Conclusion global and regional myocardial performance is transiently impaired in TTS and significantly associated with HC. Although limited by the low number of patients, these results suggest that myocardial work parameters have a good sensistivity and may have a better performance than the EF value in predicting intra-hospital complications. Larger studies will be necessary to confirm these preliminary results.

The reversible perfusion-metabolism pattern of radionuclide myocardial PET imaging in Takotsubo Cardiomyopathy: A case report

Background: Takotsubo Cardiomyopathy (TTC) is known as a syndrome of transient and acute left ventricular dysfunction caused by emotional and physiological stressors. Due to a variety of complications in the acute phase, recently, there has been increased attention to TTC

Takotsubo syndrome and COVID-19: A systematic review.

Takotsubo syndrome (TTS), also known as stress cardiomyopathy, is characterized by acute and transient left ventricular dysfunction and has increased during the COVID-19 pandemic. Herein, we aim to review studies on TTS that were associated with COVID-19 infection, vaccine, and other COVID-19-related etiologies including psychosocial stressors. We systematically searched PubMed, EMBASE, and Scopus up to May 12, 2022. We included case reports, case series, and original articles that reported at least one TTS case associated with COVID-19, or TTS cases after receiving COVID-19 vaccines, or TTS cases secondary to psychological stress due to the COVID-19 pandemic. The quality assessment was conducted using the Joanna Briggs Institute checklist. Sixty-seven articles including 102 cases were included. Hypertension was the most frequently accompanying comorbidity (N = 67 [65.6%]) and the mean left ventricular ejection fraction was 36.5%. Among COVID-19 patients, the in-hospital mortality rate was 33.3%. On the other hand, only one COVID-19-negative individual expired (2.3%). The most common presenting clinical symptom was dyspnea in 42 (73.6%) patients. the mean time interval from the first symptom to admission was 7.2 days. The most common chest imaging finding was ground-glass opacity which was reported in 14 (31.1%) participants. The most common abnormalities were T-wave inversion in 35 (43.2%) and ST-segment elevation in 30 (37%). Brain natriuretic peptide and troponin were elevated in 94.7% and 95.9% of participants, respectively. The TTS in patients with COVID-19 is almost rare, whereas it could lead to a great mortality and morbidity. An individual with COVID-19, especially an elderly woman, presented with dyspnea in addition to a rise in brain natriuretic peptide and troponin should be evaluated for TTS.

Case report of a young patient with Takotsubo Cardiomyopathy in district hospital

Takotsubo Cardiomyopathy (TCM), also known as “broken heart syndrome,” is a condition that causes transient left ventricular dysfunction in the absence of coronary artery disease. Here, we present a case of TCM in a young female patient.

Abstract 13332: Obesity Paradox in Stress Cardiomyopathy When Comparing Outcomes

Introduction:Stress Cardiomyopathy (SCM), is an acute reversible myocardial injury associated with transient left ventricular dysfunction. Risk factors include female sex, post-menopause, anxiety, depression, schizophrenia, asthma and chronic obstructive pulmonary disease, diabetes, and substance use. Obesity has an increased sympathetic tone and state of chronic metabolic stress, both of which are similar in etiology to SCM. We postulate that obesity may have high prevalence in patients with SCM. Methods: We queried the Nationwide Inpatient Sample database (2016-2019) to identify adult patients with SCM with and without obesity, along with other common co-morbidities using ICD-10 codes. We compared the categorical and continuous variables by Pearson χ2 and Student t test. Results: There were 31,725 patients with SCM. The mean age was 67.15 + 14 years and the population was predominately female, n=26409 (83.2%). Racial distribution consisted of White (n=24713 77.9%), Black (n=24713, 8%), and Hispanic (n=1918, 6%). There were 3816 (12%) who were diagnosed with obesity. When comparing both groups, obese patients were found to be younger than non-obese, 63.3 + 14 years vs. 67.68 + 13 years, p<0.001, respectively. Obese patients had higher incidences of hypertension (n=10317; 38.9% vs. 1485; 37%, p=0.005), chronic kidney disease (n=3874; 17.5% vs. n=668; 13.9%, p<0.001), dyslipidemia (n=1771; 46.4% vs. n=10625; 38.1%, p <0.001), diabetes mellitus (n=373; 9.8% vs n=1278; 4.6%, p<0.001), non-alcoholic fatty liver disease (n=30; 0.8% vs. n=68; 0.2%, p<0.001), and polycystic ovarian syndrome (n= 30; 0.8% vs n=68; 0.2%, p<0.001). Tobacco use was higher in non-obese vs. obese patients (n=311; 1.1% vs. 28; 0.7%, p=0.32). The length of stay for both groups was similar, 7-days. Obese patients had a lower total hospital charges ($95,098 vs. $98,735). There was a lower incidence of mortality among obese patients n=194 (5.1%) vs. non-obese n=1743 (6.2%), p<0.005. Conclusion: Despite obese patients having more risk factors for developing SCM than non-obese patients, they were found to have decreased mortality and a lower cost of stay. These findings suggest that obesity may play a paradoxical role in SCM.

Manganese-Enhanced Magnetic Resonance Imaging in Takotsubo Syndrome.

Takotsubo syndrome is an acute cardiac emergency characterized by transient left ventricular systolic dysfunction typically following a stressful event. Despite its rapidly rising incidence, its pathophysiology remains poorly understood. Takotsubo syndrome may pass unrecognized, especially if timely diagnostic imaging is not performed. Defective myocardial calcium homeostasis is a central cause of contractile dysfunction and has not been explored in takotsubo syndrome. We aimed to investigate myocardial calcium handling using manganese-enhanced magnetic resonance imaging during the acute and recovery phases of takotsubo syndrome. Twenty patients with takotsubo syndrome (63±12 years of age; 90% female) and 20 volunteers matched on age, sex, and cardiovascular risk factors (59±11 years of age; 70% female) were recruited from the Edinburgh Heart Centre between March 2020 and October 2021. Patients underwent gadolinium and manganese-enhanced magnetic resonance imaging during index hospitalization with repeat manganese-enhanced magnetic resonance imaging performed after at least 3 months. Compared with matched control volunteers, patients had a reduced left ventricular ejection fraction (51±11 versus 67±8%; P<0.001), increased left ventricular mass (86±11 versus 57±14 g/m2; P<0.001), and, in affected myocardial segments, elevated native T1 (1358±49 versus 1211±28 ms; P<0.001) and T2 (60±7 versus 38±3 ms; P<0.0001) values at their index presentation. During manganese-enhanced imaging, kinetic modeling demonstrated a substantial reduction in myocardial manganese uptake (5.1±0.5 versus 8.2±1.1 mL/[100 g of tissue ·min], respectively; P<0.0001), consistent with markedly abnormal myocardial calcium handling. After recovery, left ejection fraction, left ventricular mass, and T2 values were comparable with those of matched control volunteers. Despite this, native and postmanganese T1 and myocardial manganese uptake remained abnormal compared with matched control volunteers (6.6±0.5 versus 8.2±1.1 mL/[100 g of tissue ·min]; P<0.0001). In patients with takotsubo syndrome, there is a profound perturbation of myocardial manganese uptake, which is most marked in the acute phase but persists for at least 3 months despite apparent restoration of normal left ventricular ejection fraction and resolution of myocardial edema, suggesting abnormal myocardial calcium handling may be implicated in the pathophysiology of takotsubo syndrome. Manganese-enhanced magnetic resonance imaging has major potential to assist in the diagnosis, characterization, and risk stratification of patients with takotsubo syndrome. URL: https://www. gov; Unique identifier: NCT04623788.

Manganese-enhanced magnetic resonance imaging in Takotsubo syndrome

Abstract Background Takotsubo syndrome is an increasingly common acute cardiac emergency characterised by profound transient left ventricular systolic dysfunction following a stressful event. Its pathophysiology remains poorly understood and a third of patients will have a major adverse cardiac or cerebrovascular event by 5 years [1]. Defective myocardial calcium homeostasis is central to contractile dysfunction and may be implicated in its pathophysiology. Manganese-enhanced magnetic resonance imaging is a novel non-invasive imaging technique that assesses myocardial manganese uptake as a measure of myocardial calcium handling [2]. Our aim was to investigate myocardial calcium handling using manganese-enhanced magnetic resonance imaging during the acute and recovery phase of takotsubo syndrome. Methods This single centre case-controlled observational longitudinal cohort study was conducted in accordance with the Declaration of Helsinki and ethical committee approval with written informed consent. Twenty patients with takotsubo syndrome and 20 age, sex and cardiovascular risk factor matched volunteers were recruited between March 2020 and September 2021. Patients underwent gadolinium and manganese-enhanced magnetic resonance imaging during the index event with repeat manganese-enhanced magnetic resonance imaging after 3 months. Myocardial manganese uptake was characterised by Patlak modelling. Results During the acute presentation, most patients had an “apical” pattern of takotsubo syndrome with reduced left ventricular ejection fraction (51±11 versus 67±8%, P&amp;lt;0.001, Figure 1), elevated left ventricular mass (89±11 versus 57±14 g/m2, P&amp;lt;0.01) and native T1 (1358±49 versus 1211±28 ms, P&amp;lt;0.001) and T2 (60±7 versus 38±3 ms, P&amp;lt;0.001) values compared to matched volunteers. Patlak modelling demonstrated reduced myocardial manganese uptake (5.1±0.5 versus 8.0±1.0 mL/100g of tissue/min, P&amp;lt;0.0001) consistent with a major abnormality of myocardial calcium handling. Reduced myocardial manganese uptake attributable to apical takotsubo syndrome could be seen in one patient, scanned 18 days after symptom onset despite apparent resolution of cardiac function. Beyond 3 months of convalescence, left ventricular mass, ejection fraction, native T1 and T2 values were comparable to matched volunteers. Despite this, myocardial calcium handling remained abnormal compared to matched volunteers (6.7±0.7 versus 8.0±1.0 mL/100 g of tissue/min, P&amp;lt;0.001, Figure 2). Conclusions In patients with takotsubo syndrome, there is a profound perturbation of myocardial calcium handling which is most marked acutely but persists after apparent recovery of left ventricular ejection fraction and resolution of myocardial oedema. Abnormal myocardial calcium handling is implicated in the pathophysiology of takotsubo syndrome and manganese-enhanced magnetic resonance imaging could play a major role in the diagnosis and risk stratification of patients with takotsubo syndrome. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Medical Research CouncilBritish Heart Foundation

Takotsubo cardiomyopathy in a female presenting with status asthmaticus: a case report and review of literature

BackgroundTakotsubo cardiomyopathy (TCM) is a non-ischemic syndrome characterized by transient acute left ventricular dysfunction as evident on transthoracic echocardiography. It can often mimic myocardial ischemia and is characterized by the absence of angiographic evidence of obstructive coronary artery disease. Reports of Takotsubo syndrome in elderly with asthma exacerbations have been noted.Case presentationWe describe a case of TCM in a 68-year-old female who presented with acute shortness of breath secondary to status asthmaticus. Her electrocardiogram showed ST segment elevations in multiple coronary artery distributions and mildly elevated troponin levels. Coronary angiography showed no significant stenosis of the coronary arteries with left ventriculography that showed systolic apical ballooning with a 10% ejection fraction, consistent with TCM.ConclusionsTakotsubo syndrome should be considered in the differential diagnosis of patients presenting with status asthmaticus and elevated troponin levels on admission. Patients should be asked about the use of beta agonist prior to admission. A thorough literature review including a summary of 11 previously published case reports of TCM with acute asthma exacerbations has been presented.

Takotsubo сardiomyopathy: case report

Stress-induced cardiomyopathy, also known as takotsubo cardiomyopathy (TCM), is a type of reversible left ventricular dysfunction that occurs after emotional or physical stress and manifests as chest pain, electrocardiographic changes mimicking myocardial ischemia, cardiac enzyme elevation, transient left ventricular dysfunction involving mid and apical segments and normal or near-normal coronary angiography. This syndrome could happen after iatrogenic stressors like anesthesia or surgery. We hereby present two cases of TCM after anesthesia and surgery. In both cases, clinical, electrocardiographic, echocardiographic, and angiographic findings are employed to confirm this diagnosis.

Cardiac Assessment in Children with MIS-C: Late Magnetic Resonance Imaging Features.

Multisystem Inflammatory Syndrome (MIS-C) is a new entity that emerges 2–4 weeks after the SARS-CoV-2 infection in children. MIS-C can affect all systems, the most severe of which is cardiac involvement. The duration of the cardiac symptoms is still uncertain and may be persistent or prolonged. The American College of Rheumatology Clinical Guidelines recommends cardiac magnetic resonance imaging (MRI) 2–6 months after the diagnosis of MIS-C in patients presenting with significant transient left ventricular (LV) dysfunction in the acute phase of illness (LV ejection fraction 50%) or persistent LV dysfunction. There are a few studies investigating cardiac MRI findings in MIS-C patients. In this study, we aimed to evaluate cardiac MRI findings, at the earliest 3 months after diagnosis, and compare these findings with the echocardiograms in children with MIS-C. A retrospective study including 34 MIS-C patients was conducted at a tertiary-level University Hospital between June 2020 and July 2021. Centers for Disease Control and Prevention criteria were used in the diagnosis of MIS-C. Cardiac MRI was performed at least 3 months after MIS-C diagnosis. The study included 17 (50%) boys and 17 (50%) girls with a mean age of 9.31 ± 4.72 years. Initial echocardiographic evaluation revealed cardiac abnormality in 13 (38.2) patients; 4 (11.8%) pericardial effusion, 4 (11.8%) left ventricular ejection fraction (LVEF) < 55%, and 5 (14.7%) coronary artery dilatation. Echocardiography showed normal LV systolic function in all patients during follow-up; coronary dilatation persisted in 2 of 5 (40%) patients at the 6th-month visit. Cardiac MRI was performed in 31 (91.2%) patients, and myocardial hyperemia was not detected in any patients (T1 relaxation time was < 1044 ms in all children). However, 9 (29%) patients’ MRI showed isolated elevated T2 levels, and 19 (61.3%) revealed at least one of the following findings: pericardial effusion, right ventricular dysfunction, or LVEF abnormality. In patients with MIS-C, a high rate of cardiac involvement, particularly pericardial effusion was determined by cardiac MRI performed at the earliest 2–6 months after diagnosis. Even if echocardiography does not reveal any abnormality in the initial phase, cardiac MRI should be suggested in MIS-C patients in the late period. This is the first study reporting cardiac MRI findings in the late period of MIS-C patients.

Reverse Takotsubo Cardiomyopathy in a Patient With Commotio Cordis

Takotsubo cardiomyopathy (TCM), also known as stress cardiomyopathy or “broken heart syndrome”, is characterized by acute transient regional left ventricular systolic dysfunction in the absence of obstructive coronary artery disease or acute plaque rupture. Atypical forms and rare anatomical variants can have different presentations; hence, recognition becomes more important. Prognosis is much more favorable if managed appropriately. An equally infrequent cause of cardiac arrest is commotio cordis (CC). This is defined as sudden cardiac death secondary to a blunt chest wall impact leading to ventricular arrhythmias. We report a case with findings of TCM and/or CC in a patient with a blunt chest trauma in the setting of motor vehicle accident.

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 Following Traumatic Hand Amputation: A Case Report.

IntroductionTakotsubo or stress cardiomyopathy is a syndrome of transient left ventricular systolic dysfunction seen in the absence of obstructive coronary artery disease.Case ReportWe describe a case of stress cardiomyopathy diagnosed in the emergency department (ED) using point-of-care ultrasound associated with traumatic hand amputation. The patient suffered a near-complete amputation of the right hand while using a circular saw, subsequently complicated by brief cardiac arrest with rapid return of spontaneous circulation. Point-of-care ultrasonography in the ED revealed the classic findings of takotsubo cardiomyopathy, including apical ballooning of the left ventricle and hyperkinesis of the basal walls with a severely reduced ejection fraction. After formalization of the amputation and cardiovascular evaluation, the patient was discharged from the hospital in stable condition 10 days later.ConclusionEmergency physicians should be aware of the possibility of stress cardiomyopathy as a cause for acute decompensation, even in isolated extremity trauma.

Spectrum of radionuclide perfusion study abnormalities in takotsubo cardiomyopathy

BackgroundTakotsubo (stress) cardiomyopathy (TCM) is characterized by transient apical left ventricular dysfunction precipitated by emotional or physical stress. Its presentation makes it difficult to differentiate from an acute coronary syndrome. A suggestive echocardiogram plus normal coronary angiography most often are used for diagnosis. Radionuclide perfusion study (RPS) findings in TCM, including by positron emission tomography (PET), have been poorly characterized. Methods and ResultsIntermountain Healthcare electronic medical records were searched from 2009 to 2019 for patients with a discharge diagnosis of TCM, stress CM, or takotsubo syndrome. 16 TCM patients with an RPS, including by PET in 8, were identified: 13 (81%) were women; age averaged 72 years (50-89 years); 14 had an identified stressor. TCM diagnosis was definite in 11 and probable/possible in 5. RPS was abnormal in 11, with 9 showing an apical perfusion deficit, whereas angiography in 14 showed normal coronaries in 12 and non-obstructive disease in 2. Echo ejection fraction averaged 41% (29%-60%); an apical wall motion abnormality was present in 14 (88%). Troponin elevations were noted in 14/15. The presenting ECG was abnormal is 14, frequently showing ST-T-wave abnormalities. 13 patients were discharged on a beta-blocker. Follow-up echo (in 12) showed recovered ejection fraction in 9 and recovered apical wall motion in 11. ConclusionsDespite having normal or non-obstructive epicardial coronary arteries on angiography, TCM patients frequently present with apical wall motion abnormalities and matching RPS perfusion defects. These findings suggest microvascular abnormalities, whose pathophysiology, temporal course, and clinical implications should be the subject of further investigation.

Takotsubo Syndrome in the Emergency Room - Diagnostic Challenges and Suggested Algorithm.

Takotsubo syndrome is an important condition to consider among patients with acute chest pain in the emergency room. It often mimics acute coronary syndrome since chest pain and ECG changes are key features in both conditions. The hallmark of takotsubo syndrome is transient left ventricular dysfunction (characterized by apical ballooning) followed by complete echocardiographic recovery in most cases. Although most patients exhibit a benign course, lethal complications may occur. The use of hand-held point-of-care focused cardiac ultrasound may be helpful for early identification of takotsubo syndrome and distinguishing it from acute coronary syndrome and other cardiovascular emergencies. Emergency room physicians should be familiar with typical and atypical presentations of takotsubo syndrome and its key electrocardiographic changes. The approach in the emergency room should be based on a combination the clinical presentation, ECG, and handheld echocardiography device findings, rather than a single electrocardiographic algorithm.

Takotsubo cardiomyopathy after cryoballoon pulmonary vein ablation in a patient with persistent atrial fibrillation: clinical case

We present a case of takotsubo cardiomyopathy characterized as acute transient left ventricular systolic dysfunction in a patient with persistent atrial fibrillation, that occurred after cryoballoon pulmonary vein ablation procedure.

Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications.

Takotsubo syndrome is a condition characterized by acute transient left ventricular systolic dysfunction, which at presentation can be challenging to distinguish from acute myocardial infarction. Although previously thought to be a benign, self-limiting condition, recent studies have confirmed that patients with takotsubo syndrome have persistent subtle ongoing cardiac dysfunction, and many continue to have limiting symptoms despite restoration of left ventricular ejection fraction. Moreover, these patients have a substantial burden of morbidity as well as mortality with high rates of subsequent major adverse cardiovascular events that approach those of patients with acute coronary syndrome. The mechanisms behind this condition remain elusive. Despite substantial research, the medical community continues to have an incomplete understanding of its underlying etiology and pathophysiology. Catecholamine-induced myocardial injury is the most established and well-known theory, but this does not explain all of the clinical features and presentations of the condition, and numerous other pathways and abnormalities are emerging. Because of the poor understanding of its underlying pathophysiology, there is a lack of evidence-based interventions to treat the acute episode, to avoid recurrences and to prevent major adverse cardiovascular events. This highlights the need for further research to gain a better understanding of the underlying pathophysiology in order to inform appropriate randomized controlled trials of interventions targeting the causative pathways. Only then can evidence-based management strategies be established to improve clinical outcomes of this potentially lethal condition.

Clinical case of a patient at risk of perioperative recurrence of takotsubo cardiomyopathy

Introduction.Takotsubo syndrome is a new nosological form of acquired cardiomyopathy characterized by transient left ventricular dysfunction in response to physical or psychoemotional stress, clinically and electrocardiographically resembling acute coronary syndrome. Takotsubo cardiomyopathy is a form of stress cardiomyopathy simulating acute myocardial infarction with electrocardiographic and biochemical changes. Despite a large number of publications, there is no definitive understanding of the etiopathogenesis, clinical picture, treatment, as well as measures to prevent the development of takotsubo cardiomyopathy. With the manifestation of takotsubo cardiomyopathy in the perioperative period, the clinical picture may be even less specific, which inevitably leads to diagnostic difficulties. Given that the main trigger of the disease is stress, the development of this disease is an urgent problem of anesthesiology and intensive care. In addition, there is a problem of managing patients with a history of takotsubo cardiopathy, if they need surgical interventions.The aim of the workwas to prove the effectiveness of a number of approaches (premedication with the use of barbiturates and α2-adrenoceptor agonists; monitoring the depth of anesthesia; administration of narcotic analgesics in continuous infusion; use of local anesthetics for skin anesthesia; multimodal anesthesia in the postoperative period) to the perioperative management of patients with a high risk of CT recurrence.Materials and method.We present a clinical case demonstrating the possible tactics of perioperative management of a patient with a history of CT that manifested during anesthesia when a follow-up benefit was needed. The clinical picture is described, the results of instrumental and laboratory investigations indicating a correct CT diagnosis are presented.Results.An individual strategy for perioperative management of the patient was developed and implemented, which made it possible to avoid a CT recurrence. Discussion. The etiopathogenesis of the disease and analysis of the few literature sources on the topic allow us to propose a number of approaches to the perioperative management of patients at risk of recurrence of CT.Conclusions.A number of approaches (premedication with barbiturates and α 2-adrenoceptor agonists; anesthesia depth monitoring; administration of narcotic analgesics in continuous infusion mode; use of local anesthetics for skin anesthesia; multimodal anesthesia in the postoperative period) to perioperative management of patients with high risk of CT recurrence were demonstrated to be successful.

Five-year follow-up and outcomes of takotsubo/stress cardiomyopathy in a single centre- an irish perspective

Abstract Funding Acknowledgements Type of funding sources: None. Background Takotsubo Cardiomyopathy (TC) is an acute cardiac presentation characterised by acute myocardial injury and transient left ventricular systolic dysfunction, in the absence of obstructive coronary disease(1). Postulated causes include catecholamine excess, microvascular dysfunction, and multi-vessel coronary artery spasm. Predominantly seen in post-menopausal women, frequently triggered by emotional or physical stressor with in-hospital mortality rate reported at 2-5%(2). We present a single centre experience of TC with five-year follow-up. Methods We performed a retrospective descriptive study of patients with a diagnosis of TC coded by Hospital In-Patient Enquiry data from a tertiary level Irish hospital between 2010 and 2016. Data collection was electronic patient records/chart review. 21 cases were confirmed by modified Mayo Clinic criteria(3). Three patients were lost to follow up, two patients died during the follow-up period and one patient was excluded due to a focal area of transmural infarction on follow-up cardiac magnetic-resonance imaging (CMRI). Follow up data was obtained on sixteen patients up to 01/08/2021. Statistical analysis using SPSS v. 27, expressed as mean +- SD in %. Results Mean age at event was 64 +/- 12 years, 95% were female. Triggers identified in 55% of cases; emotional stressors in 35%, physical stressors in 25%. All had raised Troponin I (peak 3.13 ± 2.42ng/ml) and electrocardiograph (ECG) changes. Coronary angiography performed in all with no or mild CAD in seventeen and moderate CAD in two cases. CMRI was performed in 60% (n = 12) at on average 14.8 months post discharge. Average left ventricular ejection fraction (LVEF) was 31+/- 8% and 62+/-7% at diagnosis and follow up respectively, improving in all cases with mean improvement of 30.8 +/-11% (p &amp;lt; 0.001). Three patients had a further TC event. Two of the cases underwent angiography at the time of second presentation with normal coronary arteries and follow-up imaging showed full LVEF recovery in both cases. The third patient is awaiting follow-up CMRI. Of the recurrent cases two occurred despite best medical therapy. Two of the cases showed full recovery of LVEF between events and one showed minimal LVEF improvement prior to recurrence but full recovery after the second event. All patients who remained in Ireland had initial follow up (n = 15), 46% attend Cardiology outpatients in 2021. Conclusions Our demographic data is similar to previous studies with the majority of cases occurring in postmenopausal women(4). Our mortality rate was 9.5%, current published prognostic data in TC are limited and conflicting(2). The recurrence rate among our small cohort was 16.6% (n = 3) despite cardio-protective medications in two of the three cases, higher than previous reviews(5). The time to clinical and imaging follow up was discordant but all patients in our follow up group regained a normal LVEF which is very reassuring and in-keeping with prior studies. Abstract Figure. TTE apical 4-chamber view Abstract Figure. CMRI 4-chamber view end systole

Differentiating typical tako tsubo syndrome from extensive anterior ST-elevation myocardial infarction: look behind the anterior wall

Abstract Funding Acknowledgements Type of funding sources: None. Tako-Tsubo Syndrome (TTS) consists in transient left ventricular dysfunction resembling in its typical form acute anterior ST-elevation myocardial infarction (STEMI). Early non-invasive differential diagnosis, crucial for therapeutic purposes, appears difficult according to available data. Purpose to systematically analyze LV function and ECG changes in patients with acute anterior STEMI and TTS, to identify parameters possibly useful for differential diagnosis. Methods this is a retrospective cohort study, with 2 groups: patients with anterior STEMI and extensive apical involvement at echocardiography (n = 22); patients with TTS (n = 22) and ECG changes diagnostic for anterior STEMI at presentation (n = 22). They underwent a comprehensive clinical and echocardiographic evaluation in acute phase, including 2D speckle tracking longitudinal strain. We created new indexes based on wall motion impairment of inferior and inferior-lateral walls: the Inferior apex ratio (IAR) and inferior-lateral apex ratio (ILAR) (see picture). Results TTS and STEMI patients were similar for age (74.7 ± 9.1 vs 73.4 ± 14.1 y), sex, and main biochemical data except for higher peak troponin I in STEMI (1323 ± 622 vs 377 ± 220 ng/L, p = 0.01). ST segment elevation in V1 (V1e) was significantly less common in TTS (p &amp;lt; 0.001) while increased ratio of ST segment elevation in V4-V6 to V1-V3 (∑Ste V4-V6/∑Ste V1-V3≥1) was more common in TTS (p &amp;lt; 0.001). Among ECG parameters, absence of V1e had the best sensitivity (86%) and specificity (86%) in predicting TTS. LVEF values were similar (means: 45% in both groups) with EDVI greater in TTS (55.5 ±12.3 vs 46.6 ± 11.0 ml/m2, p = 0.02). WMSI was greater in TTS patients (2.2 ± 0.1 vs 1.9 ± 0.1, p &amp;lt; 0.0001), mainly for greater scores of mid segments. Global longitudinal strain was impaired in TTS (-8.1 ± 2.5 %) and in anterior STEMI (-7.9 ± 2.7, p = 0.8). By analyzing the single segments, strain was significantly more compromised in TTS in mid inferior (MI) (-4.3 ± 6.4 vs -9.9 ± 5.5 % in STEMI, p = 0.003) and mid inferior-lateral (MIL) segments (-5.4 ± 5.4 vs -9.6 ± 4.9 %, p = 0.009). Mean IAR was 0.7 ± 0.3 in TTS vs 1.8 ± 0.6 in STEMI, p &amp;lt; 0.0001; mean ILAR was 0.7 ± 0.1 in TTS vs 2.0 ± 0.9 in STEMI, p &amp;lt; 0.0001. ILAR was &amp;lt; I in all TTS patients, and &amp;gt; 1 in all STEMI cases. IAR &amp;lt; 1 showed 90% sensitivity and 95% specificity in predicting TTS. By multivariate linear regression analysis, strain values of MI and MIL segments were significantly associated with TTS (Beta: -0.98 and -0.97 respectively, p &amp;lt; 0.0001), independently from age, sex, and EDVI. IAR and ILAR values were significantly associated with TTS (Beta: -0.81 and -0.76 respectively, p &amp;lt; 0.0001) independently from the same co-variates as above. Conclusions evidence of impaired contractility extending beyond apex to mid inferior and inferior-lateral walls, assed by longitudinal strain or by IAR and ILAR, can help to discriminate TTS from extensive anterior STEMI, more accurately than ECG parameters. Abstract Figure. Examples of ILAR index Abstract Figure. IAR and ILAR distributions