Ventricular Ballooning Research Articles

Acute Left Ventricular Ballooning: Tools to Differentiate Hypertrophic Cardiomyopathy with Outflow Obstruction from Neurohumoral Takotsubo Syndrome.

Despite considerable interest in the syndrome of acute left ventricular (LV) ballooning, its pathophysiology has remained ill-defined. In this review, we explore observational data describing two etiologies of acute LV ballooning: neurohumoral classic Takotsubo Syndrome (TTS), and acute severe unrelenting left ventricular outflow tract (LVOT) obstruction in patients with obstructive hypertrophic cardiomyopathy (HCM). We describe the clinical presentation and varying pathophysiology of these presentations, explore how echocardiography and cardiac catheterization may help differentiate between the two etiologies, and detail differences in management. We highlight the significant overlap as well as key differentiating features of these conditions, with the aim to improve diagnostic awareness and accuracy and appropriately tailor therapy.

Syndrome of Reversible Cardiogenic Shock and Left Ventricular Ballooning in Obstructive Hypertrophic Cardiomyopathy.

BackgroundCardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction.Methods and ResultsWe analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β‐blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra‐aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function.ConclusionsWhen cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function.

STRESS AND SHOCK: CASE OF MECHANICAL CIRCULATORY SUPPORT IN TOXIC SHOCK

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sepsis may induce stress-induced cardiomyopathy by increased catecholamines. Although reversible, In severe cases this may lead to ventricular arrhythmias, thromboembolism, and cardiogenic shock. There is increased hospital mortality with age >80, black race, and presence of multi organ failure. CASE PRESENTATION: 52 yo black male with unknown medical history presents with belligerent behavior and shortness of breath. He was noted to be febrile to 108F, hypotensive with MAPs in the 40s, tachycardic to 140s, and hypoxic to 79% on room air. Labs significant for WBC 1, Cr 4.2, lactic acid 11.7, CK 2407, Troponin 0.104. ABG showed pH 7.19, pCO2 54, pO2 48, FiO2 100%. Chest xray showed bilateral interstitial and airspace opacities. Patient was intubated for hypoxic and hypercapnic respiratory failure and started on norepinephrine, vasopressin, and epinephrine with 5L fluid bolus and stress dose steroids. TTE demonstrated left ventricle apical and mid wall segment akinesis with left ventricular ballooning. VA-ECMO emergently initiated for ARDS management and Impella was placed for cardiogenic shock secondary to sepsis-induced Takotsubo cardiomyopathy. Sputum cultures returned positive for MRSA and Streptococcus pyogenes. Antibiotics changed to vancomycin, zosyn, azithromycin, cefepime, and clindamycin to account for toxic shock. Hospital course was complicated by development of pancytopenia requiring use of granix, atrial fibrillation with rapid ventricular rate requiring emergent cardioversion, and renal failure requiring CRRT. Impella was removed on the sixth hospital day and the patient started on dobutamine. Patient eventually developed critical limb ischemia in all four extremities with need for bilateral hand and hip disarticulations. On the ninth hospital day, the patient was transitioned to comfort care and passed away. DISCUSSION: In the case above, toxic and septic shock caused stress-induced cardiomyopathy that required VA-ECMO and Impella. In the adult population, VA-ECMO has not been widely used in the treatment of refractory shock and outcomes with VV-ECMO have been better than VA-ECMO. This is likely due to VA-ECMO's use in profound hypoperfusion and higher incidence of neurological complications, renal failure, and limb ischemia. The addition of Impella helps unload the left ventricle and helps with EMCO weaning. CONCLUSIONS: Studies have found that better outcomes were associated with door-to-ECMO times of ≤96 hours, Gram-positive sepsis, and pneumonia rather than primary bloodstream infections. Though our patient met all of these criteria, his case still resulted in poor outcomes. REFERENCE #1: Cheng A, Sun HY, Tsai MS, Ko WJ, Tsai PR, Hu FC, Chen YC, Chang SC. Predictors of survival in adults undergoing extracorporeal membrane oxygenation with severe infections. The Journal of thoracic and cardiovascular surgery. 2016 Dec 1;152(6):1526-36. REFERENCE #2: Nabzdyk CS, Couture EJ, Shelton K, Cudemus G, Bittner EA. Sepsis induced cardiomyopathy: Pathophysiology and use of mechanical circulatory support for refractory shock. Journal of critical care. 2019 Dec 1;54:228-34. REFERENCE #3: Schmitz, M., Roux, X., Huttner, B. et al. Streptococcal toxic shock syndrome in the intensive care unit. Ann. Intensive Care 8, 88 (2018). https://doi.org/10.1186/s13613-018-0438-y DISCLOSURES: No relevant relationships by Debapria Das, source=Web Response No relevant relationships by Abigail Go, source=Web Response No relevant relationships by Daniele Valentini, source=Web Response

Spontaneous coronary artery dissection and takotsubo syndrome: An often overlooked association; review.

Spontaneous coronary artery dissection (SCAD) and takotsubo syndrome (TS) are two cardiovascular syndromes with predilection for women. Both conditions may be preceded by an emotional stress or, for the affected individual, an unusual severe physical exercise. "Restitution ad integrum" occurs in most cases suffering from SCAD or TS with complete angiographic resolution of the dissected vessel and left ventricular dysfunction respectively. Recently, many cases, which were initially diagnosed as TS because of typical left ventricular ballooning pattern showed to have SCAD, have been reported; these cases were deemed to be "SCAD misdiagnosed as TS". The left ventricular wall motion abnormality has been attributed to the ischemia caused by SCAD-affected coronary vessel especially in the left anterior descending artery (LAD) with "wrap-around course". However, the left ventricular ballooning pattern have occurred in patients with SCAD in non-long-wrap-around LAD and SCAD in other coronary branches where coronary ischemia on its own cannot explain the left ventricular ballooning. In this review, sufficient data supporting the evidence for the possibility of coexistence of SCAD and TS is provided. Misdiagnosis of the association of the two conditions may result in mismanagement of the patient with undesirable consequences. Furthermore, the causal links between SCAD and TS is discussed.

A rare case of atypical mid-variant takotsubo cardiomyopathy during dobutamine stress echocardiography (RCD code: III-5B)

Dobutamine stress echo (DSE) allows for a relatively safe and accurate assessment of ischaemia in patients, who are unable to exercise. Side effects of DSE include nausea, vomiting, and in certain cases, excessive rise and fall in blood pressures. However, in the setting of an intrinsic catecholamine surge, dobutamine stress testing can lead to transient ventricular ballooning. Here, we report a case of a 66‑year‑old female who developed chest pain with ST‑segment elevation on electrocardiogram (ECG) along with wall motion abnormalities seen on transthoracic echocardiogram (TTE) during dobutamine stress testing. Her urgent coronary angiogram showed non‑obstructive coronaries with systolic mid‑anterolateral and antero‑septal wall ballooning on left ventriculogram with basal and apical sparing. The ECG changes resolved prior to discharge and cardiac function returned to normal on follow‑up at 3 months. The absence of obstructive coronary lesions with wall motion abnormalities on TTE and left ventriculogram, followed by the return of cardiac function to normal on follow‑up TTE highlights this case as a unique occurrence of a dobutamine‑induced, mid‑ventricular variant, atypical takotsubo cardiomyopathy. To the best of our knowledge, this is the first case of mid variant atypical takotsubo cardiomyopathy occurring secondary to dobutamine administration reported from the Indian subcontinent. The occurrence of this phenomenon points towards an extremely rare effect that may occur as a consequence of stress testing with dobutamine. JRCD 2018; 3 (6): 214–218.

A type of anteroseptal left ventricular ballooning in apatient with Takotsubo cardiomyopathy.

A type of anteroseptal left ventricular ballooning in apatient with Takotsubo cardiomyopathy.

Pathophysiology of Takotsubo Syndrome

Originally described by Japanese authors in the 1990s, Takotsubo syndrome (TTS) generally presents as an acute myocardial infarction characterized by severe left ventricular dysfunction. TTS, however, differs from an acute coronary syndrome because patients have generally a normal coronary angiogram and left ventricular dysfunction, which extends beyond the territory subtended by a single coronary artery and recovers within days or weeks. The prognosis was initially thought to be benign, but subsequent studies have demonstrated that both short-term mortality and long-term mortality are higher than previously recognized. Indeed, mortality reported during the acute phase in hospitalized patients is ≈4% to 5%, a figure comparable to that of ST-segment-elevation myocardial infarction in the era of primary percutaneous coronary interventions. Despite extensive research, the cause and pathogenesis of TTS remain incompletely understood. The aim of the present review is to discuss the pathophysiology of TTS with particular emphasis on the role of the central and autonomic nervous systems. Different emotional or psychological stressors have been identified to precede the onset of TTS. The anatomic structures that mediate the stress response are found in both the central and autonomic nervous systems. Acute stressors induce brain activation, increasing bioavailability of cortisol and catecholamine. Both circulating epinephrine and norepinephrine released from adrenal medullary chromaffin cells and norepinephrine released locally from sympathetic nerve terminals are significantly increased in the acute phase of TTS. This catecholamine surge leads, through multiple mechanisms, that is, direct catecholamine toxicity, adrenoceptor-mediated damage, epicardial and microvascular coronary vasoconstriction and/or spasm, and increased cardiac workload, to myocardial damage, which has a functional counterpart of transient apical left ventricular ballooning. The relative preponderance among postmenopausal women suggests that estrogen deprivation may play a facilitating role, probably mediated by endothelial dysfunction. Despite the substantial improvement in our understanding of the pathophysiology of TTS, a number of knowledge gaps remain.

Factors Suggestive of Cardiac Complications in Takotsubo Cardiomyopathy: Multicenter Study

Background: Takotsubo cardiomyopathy (TM) is characterized by acute and transient myocardial segmental wall motion abnormality especially at the apical area with chest pain mimicking acute myocardial infarction. TM is generally accepted to show good prognosis, however, we experience some cases with severe cardiac complications including acute heart failure (AHF), cardiac rupture and ventricular arrhythmias. We characterized TM patients developing these complications. Methods and results: Eighty three patients were studied. Patients with AHF, cardiac rupture, ventricular arrhythmias and death due to cardiac complications (CC group, n = 29) were compared with other patients without cardiac complications (NC group, n = 54). There was no difference between the two groups in age, sex, and coronary risk factors. Common primary symptom in the CC group was dyspnea but was chest pain in NC group. A preceding emotional stress was a common trigger for CC group. Left ventriculography showed significantly decreased ejection fraction in the CC group (39.7 ± 10.2% vs. 53.9 ± 14.1%, p = 0.002). Similarly, more than two segments of impaired left ventricular wall motion was a significant predictor of severe cardiac complications. Conclusions: Clinical onset with dyspnea and extended area of left ventricular ballooning are signs predicting cardiac complications in TM. Received Date: March 29, 2016 Accepted Date: May 02, 2016 Published Date: May 12, 2016 Citation: Isobe, M., et al. Factors Suggestive of Cardiac Complications in Takotsubo Cardiomyopathy: Multicenter Study. (2016) J Heart Cardiol 2(2): 16. Open Access Review Article

Cardiovascular Abnormalities Among Patients with Spontaneous Subarachnoid Hemorrhage. A Single Center Experience

Objective: To assess the cardiovascular abnormalities in patients with spontaneous subarachnoid hemorrhage (SAH). Methods: All patients admitted to our institution with a primary diagnosis of spontaneous SAH and had a transthoracic echocardiogram (TTE) performed from 1st of July 2011 until 30th of May 2014 were enrolled. Results: Out of 2058 patients admitted to our institution with a diagnosis of SAH, over a three year period, only 244 patients (12%) had TTE performed during the index hospitalization. In this selected cohort, the mean age was 59 years and 66% of patients were female. Elevated troponin T was noticed in 37% of patients and QTc prolongation was the commonest ECG abnormality occurring in 49% of the patients. Thirty nine patients (16%) had a resting segmental wall motion abnormality on the TTE, including five patients with apical ballooning. In-hospital mortality was 15.6% (38 patients). Conclusion: Cardiovascular abnormalities in selected patients with SAH who had cardiac ultrasound are relatively common; however the incidence of ventricular ballooning is low. In order to attain the correct incidence of cardiovascular abnormalities in SAH patients, all patients admitted with SAH should undergo TTE and have ECG and cardiac markers checked during their hospitalization.

Abstract 17681: Stress Cardiomyopathy Developed in Patients With Cancer: Clinical Characteristics and Outcomes

Introduction: Sporadic case reports have shown that stress cardiomyopathy (SCM) can happen during treatment of underlying malignancy. However, clinical association between cancer and SCM needs further investigation. Methods: Echocardiographic data base from Jan 2009 to June 2014 was used to identify SCM patients in whom clinical and imaging data information was used to rule out classic myocardial infarction. Clinical characteristics, underlying comorbidities, and outcomes including in-hospital mortality were explored. Results: We retrospectively identified 549 consecutive patients (age, 64±15 years; 328 female) with SCMP in a single tertiary referral hospital. Among them, 210 patients had an active history of cancer (group 1, 38%), whereas the resting 339 did not (group 2). Hematologic malignancy including leukemia, lymphoma and multiple myeloma was the most common (n=44, 21.0%), followed by lung (n=39, 18.6%), stomach (7.6%), ovary (6.2%), and colorectal cancer (5.7%). Group 1 was characterized by younger age (62±13 vs. 65±16 years, p=0.002) with lower frequency of coronary risk factors, lower prevalence of female gender (54±63%, p=0.04), and lower frequency of underlying comorbidities including renal failure, stroke and heart failure. Physical illness associated with underlying medical conditions such as sepsis was the most common triggering event (79%), followed by routine surgery or procedure (18%); SCM triggered by emotional stress is very rare (<5%). Typical apical ballooning was present in 70% with atypical apical-sparing ballooning in 30% and this pattern did not show any difference between two groups. Left ventricular ejection fraction was lower in group 1 with higher prevalence of right ventricular ballooning, pulmonary hypertension and pericardial effusion. Hospital mortality was higher in group 1 (29% vs 20%, p=0.017) and active history of cancer was an independent factor associated with hospital mortality (odds ratio 1.60, 95% CI 1.063 - 2.410, p = 0.024). SCM development was not associated with history and timing of chemotherapy, which did not affect hospital mortality either. Conclusions: Cancer is an important risk factor of SCM development in a tertiary referral hospital and should be considered a poor prognostic factor.

Abstract 17041: Impact of Different Patterns of Left Ventricular Ballooning in Patients With Stress (Takotsubo) Cardiomyopathy: Single Center Clinical Experience

Introduction: Stress cardiomyopathy (SCMP) is characterized by acute reversible left ventricular (LV) dysfunction, and it is well accepted that SCMP can show various patterns with or without apical involvement. However, clinical data describing characteristics and outcomes according to the patterns of LV ballooning are lacking. Methods: We retrospectively identified 549 consecutive patients (age, 64±15 years; 328 female) with SCMP in a single tertiary hospital from Jan 2009 to June 2014. They were divided into 2 groups with typical apical ballooning (group 1) and atypical patterns sparing the LV apical segment (group 2). Clinical characteristics and outcomes including in-hospital mortality were explored. Results: Apical ballooning was most common (n=394, 71.8%) and group 2 included mid-ventricular ballooning (21.7%), basal ‘inverted’ ballooning (2.9%), global hypokinesia (1.8%), localized ballooning (1.1%), and isolated right ventricular ballooning (0.7%). Group 1 was characterized by higher mean age (67±13 vs. 55±17 years, p<0.001) with higher prevalence of coronary risk factors including obesity, hypertension, hyperlipidemia and diabetes mellitus. Emotional stress was a triggering event in a very limited patients comprising < 5%, whereas physical stress associated with underlying medical conditions comprised more than 70%. Distribution of triggering events was similar between groups. ECG abnormalities including T wave inversion, ST segment elevation, QT prolongation and atrial fibrillation were more frequent in group 1 than group 2 with lower LV ejection fraction. However, in-hospital mortality was comparable between groups (24% vs. 21%, p=0.52). Conclusions: Apical sparing ballooning develops in up to 30% of patients with SCMP. Younger age, favorable medical conditions, less severe ECG changes, and higher LV ejection fraction cannot translate to lower mortality in this group. Physicians’ vigilance is needed to improve clinical outcomes.

ECG in patients with tako tsubo cardiomyopathy

Takotsubo cardiomyopathy, also known as transient left ventricular ballooning and stress myocardiopathy, has been diagnosed increasingly more over the last decade. The takotsubo syndrome mimics acute myocardial infarction in symptoms and in electrocardiographic findings. There are two major types of takotsubo cardiomyopathy: the classical type with left ventricular apical ballooning and a type with midventricular ballooning. Both types show different electrocardiographic patterns at presentation. The present article describes classical electrocardiographic findings of the acute and subacute phases of takotsubo cardiomyopathy.

“Ballooning” patterns in takotsubo cardiomyopathy reflect different clinical backgrounds and outcomes: a BOREAS-TCM study

Whether different patterns of ventricular ballooning in takotsubo cardiomyopathy (TCM) reflect differences in trigger mechanisms or clinical outcomes is unclear. Here we examined differences in the clinical characteristics of typical and atypical forms of TCM. TCM patients (n = 251) in the BOREAS Registry were enrolled for comparison of TCM with apical ballooning (type A, n = 217) and TCM with non-apical ballooning (type non-A, n = 34). The percentage of females was significantly lower in the type non-A group (58.8 vs. 75.6 %), while other demographic parameters and triggers of TCM were similar in the two groups. Rate of mid-ventricular obstruction (MVO) was lower (2.9 vs. 14.3 %) in the type non-A group than in the type A group, though left ventricular ejection fractions in the two groups were comparable. During a follow-up period of 2.6 ± 2.8 years, TCM recurred in 2.9 % of the patients and cardiac death occurred in 4.0 %. Cox proportional hazard analysis indicated that body mass index (hazard ratio [HR]: 0.75, 95 % confidence interval [CI] 0.54-0.99) and MVO (HR: 14.71, CI 1.87-304.66) were determinants of TCM recurrence and that advanced age (HR: 1.09, CI 1.02-1.17) and cardiogenic shock (HR: 4.27, CI 1.07-18.93) were significantly associated with cardiac death. In conclusion, approximately 20 % of TCM patients show non-apical left ventricular ballooning, and female sex and MVO are less frequent in this type than in apical ballooning type TCM. Low body mass index and MVO are risk factors of recurrence, and advanced age and cardiogenic shock are risk factors of cardiac death in TCM.

Takotsubo cardiomyopathy in pregnancy

Abstract We have described a rare case of Takotsubo cardiomyopathy in pregnancy, which is presented with cardiac arrest (ventricular fibrillation) at onset. In this case, the transient left ventricular ballooning in absence of coronary artery disease, produced a severe impairment of cardiac function with typical echocardiographic and electrocardiographic findings. There were complications in the form of ventricular fibrillation, with recurrence due to possible Takotsubo cardiomyopathy and new malignant heart rhythm disorder that increases the mortality rate compared with the first attack of Takotsubo cardiomyopathy. Due to presented symptoms the patient has opted for the implantation of cardioverter defibrillator.

Stress-Induced Hyperviscosity in the Pathophysiology of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TC) is characterized by transient hypokinesis of the left ventricular apex or midventricular segments with coronary arteries without significant stenosis. It is often associated with emotional or physical stress; however, its pathophysiology is still unclear. In the present study, we analyzed the alterations in blood viscosity and markers of endothelial damage induced by sympathetic stimulation in patients with previous TC. Seventeen women (mean age 71 years) with previous TC, included and investigated in the TC Tuscany Registry, were compared to a control group of 8 age- and risk factor-matched women with chest pain and coronary arteries free of stenosis. All subjects underwent the cold pressor test (CPT). Before and after the CPT, the hemorheologic parameters (whole blood viscosity at 0.512 s(-1) and 94.5 s(-1), plasma viscosity, erythrocyte deformability index, and erythrocyte aggregation), catecholamines, plasminogen activator inhibitor-1 (PAI-1), and von Willebrand factor levels were assessed. The patients with TC had significantly greater baseline PAI-1 levels (p <0.01) and lower erythrocyte deformability index values (p <0.01). After CPT, both the patients with TC and the controls had a significant increase in several hemorheologic parameters, catecholamines, and von Willebrand factor levels and a decrease in erythrocyte deformability index. However, the PAI-1 levels were significantly increased only in the patients with TC. Compared to the controls, the patients with TC had significantly greater values of whole blood viscosity at 94.5 s(-1) (p <0.05), PAI-1 (p <0.01), von Willebrand factor (p <0.05) and lower erythrocyte deformability index values (p <0.01) after CPT. In conclusion, the results of the present study suggest that in patients with TC, the alterations in erythrocyte membranes and endothelial integrity induced by catecholaminergic storm could determine microvascular hypoperfusion, possibly favoring the occurrence of left ventricular ballooning.

Clinical Characteristics and Cardiovascular Magnetic Resonance Findings in Stress (Takotsubo) Cardiomyopathy

Eitel, Ingo*†; Knobelsdorff-Brenkenhoff, Florian Von‡; Bernhardt, Peter§; Carbone, Iacopo†∥; Muellerleile, Kai¶; Aldrovandi, Annachiara#; Francone, Marco∥; Desch, Steffen*; Gutberlet, Matthais**; Strohm, Oliver†; Schuler, Gerhard*; Schulz-Menger, Jeanette‡; Thiele, Holger*; Friedrich, Matthias G.† Author Information

Cardiac Magnetic Resonance Imaging in the Diagnosis of Anterolateral Left Ventricular Ballooning, a Variant of Classic Takotsubo Cardiomyopathy

Transient left ventricular apical ballooning syndrome is characterized by transient akinesis of the left ventricular apex with basal wall hyperkinesis; this is also known as Takotsubo cardiomyopathy. There are three distinct contractile LV patterns described in the literature: apical, midventricular, and basal ballooning. The apical ballooning pattern is the most frequent pattern. We describe the case of a transient anterolateral left ventricular ballooning fulfilling the definition of Takotsubo cardiomyopathy except for the contractile LV pattern. The diagnosis was supported by cardiac magnetic resonance imaging and by the fact that the anterolateral ballooning resolved completely after 6 weeks.

Clinical Characteristics and Cardiovascular Magnetic Resonance Findings in Stress (Takotsubo) Cardiomyopathy

Stress cardiomyopathy (SC) is a transient form of acute heart failure triggered by stressful events and associated with a distinctive left ventricular (LV) contraction pattern. Various aspects of its clinical profile have been described in small single-center populations, but larger, multicenter data sets have been lacking so far. Furthermore, it remains difficult to quickly establish diagnosis on admission. To comprehensively define the clinical spectrum and evolution of SC in a large population, including tissue characterization data from cardiovascular magnetic resonance (CMR) imaging; and to establish a set of CMR criteria suitable for diagnostic decision making in patients acutely presenting with suspected SC. Prospective study conducted at 7 tertiary care centers in Europe and North America between January 2005 and October 2010 among 256 patients with SC assessed at the time of presentation as well as 1 to 6 months after the acute event. Complete recovery of LV dysfunction. Eighty-one percent of patients (n = 207) were postmenopausal women, 8% (n = 20) were younger women (aged ≤50 years), and 11% (n = 29) were men. A stressful trigger could be identified in 182 patients (71%). Cardiovascular magnetic resonance imaging data (available for 239 patients [93%]) revealed 4 distinct patterns of regional ventricular ballooning: apical (n = 197 [82%]), biventricular (n = 81 [34%]), midventricular (n = 40 [17%]), and basal (n = 2 [1%]). Left ventricular ejection fraction was reduced (48% [SD, 11%]; 95% confidence interval [CI], 47%-50%) in all patients. Stress cardiomyopathy was accurately identified by CMR using specific criteria: a typical pattern of LV dysfunction, myocardial edema, absence of significant necrosis/fibrosis, and markers for myocardial inflammation. Follow-up CMR imaging showed complete normalization of LV ejection fraction (66% [SD, 7%]; 95% CI, 64%-68%) and inflammatory markers in the absence of significant fibrosis in all patients. The clinical profile of SC is considerably broader than reported previously. Cardiovascular magnetic resonance imaging at the time of initial clinical presentation may provide relevant functional and tissue information that might aid in the establishment of the diagnosis of SC.

Atypical "mid-ventricular" Tako-tsubo cardiomyopathy in a patient suffering from posttraumatic stress disorder: A case report

The syndrome of "left ventricular ballooning" summarizes an acute onset of transient extensive akinesia of several segments (apical, mid-ventricular) of the left ventricle, without significant lesions on the coronary angiogram, accompanied by chest symptoms, electrocardiographic changes, and limited release of cardiac markers disproportionate to the extent of akinesia. Initially, the vast majority of cases has been reported among Japanese population. Emotional or physical stress or other preceding triggering factors might play a key role in this reversible form of cardiomyopathy, but the precise etiology remains unknown. We describe a case of a 52-year-old woman with posttraumatic stress disorder after cerebral bleeding presenting with an atypical form of left ventricular ballooning ("midventricular ballooning") syndrome.

Stress-induced cardiomyopathy in a primary reference hospital: prevalence and clinical presentation

Summary Introduction: Stress-induced cardiomyopathy or Tako- tsubo cardiomyopathy is characterised by a transient lo- calised systolic ventricular dysfunction without epicar- dial coronary artery disease and is typically provoked by emotional or physical stress. It mainly affects women presenting a greater vulnerability of their hy- peractive sympathetic system. Aims: To determine the prevalence, clinical and paraclinical characteristics, complications, in-hospital mortality and recurrence rate of the disease in a pri- mary Swiss reference centre. Methods: Prospective data collection from 2003 to 2009 of hospitalised patients fulfilling the diagnostic criteria of Takotsubo cardiomyopathy: transient ST segment modifications, reversible apical or mid-ven- tricular akinesia, absence of evidence of epicardial coro- nary artery disease and other causes of transient left ventricular dysfunction. Results: A total of 31 patients presented with Takotsubo cardiomyopathy. 87% were female and the mean age was 72 ± 13 years. Symptoms included dyspnea or thoracic pain (74%). A trigger factor was present in 65% of the cases. The mean value of peak creatine kinase was 272 U/l and troponins 1.2 μ/L. The electrocardiograms mainly showed a ST-segment ele- vation in the precordial leads (74%) and a prolonged QTc-interval (77%). The mean left ventricular ejection fraction was 37 ± 10%. Right ventricular involvement was present in one third of the patients and was characterised by higher initial brain natriuretic pep- tide values. Three patients (10%) presented with mid- ventricular ballooning. All patients completely recov- ered their cardiac function. Atrial tachyarrhythmias (16%), mainly fibrillation, and cardiogenic shock (13%) were the most frequent complications. The recurrence rate was 6%. Conclusion: The current study is the largest sam- ple of Takotsubo cardiomyopathy patients in a Swiss primary reference centre. The results compare well with international published series. The prevalence was somewhat higher and dyspnea was more often the presenting symptom. This was likely due to the active search of the