Ventricular Ballooning Research Articles

Too sympathetic? Role of sympathoexcitation in Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is classically described as sudden and transient left ventricular apical ballooning in the absence of significant coronary artery disease. First described by Dote et al, 1 Dote K. Sato H. Tateishi H. Uchida T. Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J Cardiol. 1991; 21: 203-214 PubMed Google Scholar the cardiomyopathy was named “Takotsubo” because the narrow neck and round-bottomed left ventricle resemble a traditional Japanese octopus trap. Since the initial description of the condition, patients with transient left ventricular dysfunction have been identified with both the typical apical ballooning (AB) pattern and an alternative mid-left ventricular ballooning (MB) pattern, the “inverted Takotsubo.” 2 Kurowski V. Kaiser A. von H.K. et al. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest. 2007; 132: 809-816 Crossref PubMed Scopus (432) Google Scholar Patients present with symptoms resembling those of acute myocardial infarction, including chest pain, ST-segment elevation, and elevated cardiac enzymes. A high proportion of patients are women who develop symptoms after episodes of high emotion (after receiving bad news or being in a severe argument), and the disorder has captured the public's imagination with names such as “broken heart syndrome.” The interest of the medical profession also has been piqued, with almost 400 hits in PubMed for a search of “Takotsubo AND 2009.” Differential heart rate dynamics in transient left ventricular apical and midventricular ballooningHeart RhythmVol. 7Issue 12PreviewThe aim of the present study was to assess potential differences in cardiac autonomic nervous modulation in patients with transient left ventricular apical ballooning syndrome (AB) and the midventricular variant (MB) of this syndrome. Full-Text PDF To the Editor—Takotsubo Cardiomyopathy: A Role for Magnesium?Heart RhythmVol. 7Issue 12PreviewI read with interest the original research article on the role of sympathoexcitation in Takotsubo cardiomyopathy by Raj.1 Both classic and inverted patterns of stress cardiomyopathy have been reported in association with disorders associated with catecholamine excess, including pheochromocytoma, high-dose epinephrine infusion, and Irukandji syndrome following jellyfish envenomation.2,3 Full-Text PDF

Stress cardiomyopathy: transient basal ballooning

Stress cardiomyopathy is a reversible left ventricular dysfunction triggered by emotional stress. We describe a variant of transient left ventricular ballooning in a patient in which basal and midventricular segments are affected. This confirms that there is not just one ventricular dysfunction pattern in Takotsubo cardiomyopathy. The involvement of only the basal and midventricle segments is an intriguing observation with no clear explanation; furthermore, there are no predictive factors for the differently sited wall motion abnormalities.

Cardiogenic shock with basal transient left ventricular ballooning (Takotsubo-like cardiomyopathy) as first presentation of pheochromocytoma

Pheochromocytoma is a rare tumor that produces a distant effect by secretion of catecholamines. This tumor usually presents with hypertension and palpitations but it may also cause cardiogenic shock because of catecholamine-induced myocardial dysfunction. We describe a rare case of Takotsubo-like cardiomyopathy as first manifestation of pheochromocytoma with an unusual onset characterized by severe hypotension and transient basal left ventricular ballooning ('inverted' Takotsubo-like cardiomyopathy).

Right Ventricular Involvement and Pulmonary Hypertension in an Elderly Woman With Tako-Tsubo Cardiomyopathy

We describe a case of tako-tsubo cardiomyopathy in an elderly woman with a permanent pacemaker admitted to the ED with chest pain and dyspnea. Coronary angiography revealed normal coronary arteries. Typical left ventricular apical ballooning was demonstrated on contrast ventriculography. Left and right ventricular ballooning with pulmonary artery systolic hypertension was detected by transthoracic echocardiography. Velocity vector imaging and strain analysis showed a typical pattern of regional myocardial apical right ventricular contraction characterized by paradoxical positive longitudinal systolic strain. Biventricular involvement was associated with hemodynamic instability, signs of pulmonary vascular congestion, and bilateral basal pleural effusion. The patient's clinical condition gradually improved, and she was discharged after prolonged hospitalization. Predischarge echocardiography showed substantial recovery of left and right systolic function along with normalization of pulmonary artery systolic pressure. Right ventricular function should be carefully evaluated in patients with tako-tsubo cardiomyopathy, especially in the acute phase.

A case of inverted Takotsubo cardiomyopathy with mid left ventricular and apical right ventricular ballooning

A case of inverted Takotsubo cardiomyopathy with mid left ventricular and apical right ventricular ballooning

Occurrence of late gadolinium enhancement in ventricular ballooning or Tako-Tsubo syndrome: increased wall stress should not be overlooked

With great interest, we read the article by Rolf et al. 1 The histological basis of late gadolinium enhancement (LGE) in magnetic resonance imaging (MRI) was examined in 15 patients with transient ventricular ballooning or the so-called Tako-Tsubo syndrome. While all patients exhibited increased collagen-1 in endomyocardial biopsies, it was higher in five patients who showed LGE. After 14 days, LGE and collagen-1 normalized. Since focal LGE pattern did not match the areas of increased collagen that were diffusely spread over the left ventricle, collagen-1 alone cannot explain the occurrence of LGE. We agree that an increase of the interstitial space …

Takotsubo Cardiomyopathy

A 62-year old woman presented to our institute with dyspnea and hypotension. The electrocardiogram showed extensive ST elevation in V1-V6, with a negative T wave in leads II, III, and aVF. The troponin T concentration was 0.83 ng/mL (upper normal limit, 0.1 ng/mL). An echocardiography showed a significantly depressed left ventricular (LV) function with extensive akinesis and dyskinesis of all apical and midventricular segments, sparing the basal segments, which were contracting vigorously. The patient had an estimated LV ejection fraction of 0.35. On the basis of the typical shape of the dysfunctioning LV, the fact that the extensive wall motion abnormalities did not follow a coronary distribution pattern, and the coronary arteries were normal on angiography despite the presence of LV angiography of typical apical ballooning (Fig 1) with compensatory basal hyperkinesis, Takotsubo syndrome was diagnosed (arrows). After 2 days of supportive measures, the patient's status improved clinically, the ST elevation turned to a normal pattern, and the echocardiography showed normalization of myocardium function. The patient was discharged 2 days later. The syndrome is also known as “acute left ventricular ballooning,” “transient apical ballooning,” “ampulla cardiomyopathy,” “broken-heart syndrome,” or “human stress cardiomyopathy,” because stress has been implicated in its pathophysiology. Enhanced awareness may lead to increasing recognition of this new nosological entity as a possible complication of cardiac operations.

Unusual case of left ventricular ballooning involving the inferior wall: a case report

BackgroundTako – tsubo like syndrome (also named left ventricular apical ballooning) is an unusual cardiomyopathy with an high incidence in Japanese population of female sex, following an emotional stress. The clinical features (typical chest pain), and the electrocardiographic changes (negative T wave and persistent ST elevation in anterior leads), are suggestive of an acute myocardial infarction; nevertheless the coronary angiography show coronary arteries without lesions and the ventriculography show specific segmental dysfunction. In the literature there are many reports of typical left ventricular ballooning (apical); due to the rarity of the atypical localizations (such as mid, basal, anterior or inferior left ventricular wall) many authors think they are different physiopatologic entity.Case reportWe report a case of 50 – years old woman, with a family history of ischeamic cardiomyopathy but with no additional cardiovascular risk factors, who arrived to emergency department with a recent episode of chest pain (about 30 minutes) with electrocardiographic and echocardiographic features suggested of a inferior ST elevation myocardial infarction. Coronary angiography showed coronary arteries without atherosclerotic lesions; ventriculography showed an inferior dysfunction.ConclusionThis data can suggest for an atypical form (in term of clinical presentation and localization) of left ventricular ballooning involving the inferior wall (never described in the literature), not preceded by any emotional or physical stress. The follow – up performed by transthoracic echocardiography (2 months later) revealed a complete regression of wall motions abnormalities.

Tako-Tsubo Cardiomyopathy by Transient Dynamic Left Midventricular Obstruction

A 48-year-old woman visited the emergency department with shock due to a urinary tract infection. The patient, who had a history of hypertension and diabetes mellitus, presented with precordial ST-segment elevation and Q waves, along with an increase of cardiac enzymes. An echocardiography showed moderately reduced systolic function, severe apical left ventricular ballooning, and a dynamic left ventricular outflow tract obstruction with a pressure gradient of 109 mmHg. Coronary angiography demonstrated normal coronary arteries. At the 1-month echocardiographic follow-up, the apical ballooning and left ventricular systolic function had recovered completely. There was no residual left ventricular intra-cavity gradient at rest, but it was induced in low-dose dobutamine stress-echocardiography. We demonstrated that dynamic left midventricular obstruction in the setting of either increased catecholamine stress or hypovolemia could develop Tako-tsubo cardiomyopathy. (Korean Circ J 2009;39:37-41)

Transient left ventricular ballooning (tako-tsubo cardiomyopathy) soon after intravenous ergonovine injection following caesarean delivery

Transient left ventricular ballooning also called tako-tsubo syndrome, is increasingly being recognized as cardiomyopathy mimicking the clinical scenario of an acute myocardial infarction. Generally, it is characterized by apical ballooning appearance of the left ventricle in the presence of normal coronary arteries on the angiogram. Recently, a variant form involving the midventricle with sparing of the apical and basal segments has been described. This syndrome is more prevalent in postmenopausal woman and usually preceded by extreme emotional and/or physical stress. We describe a case never reported before of transient left ventricular ballooning occurring during the early postpartum period after ergonovine injection rapidly evolving from a ‘typical apical’ ballooning into a ‘midventricular’ myocardial dysfunction.

Transient left ventricular apical ballooning and exercise induced hypertension during treadmill exercise testing: is there a common hypersympathetic mechanism?

ObjectiveTo describe two cases of Takotsubo like myocardial contractile pattern during exercise stress test secondary to hypertensive response.BackgroundTreadmill exercise testing is known to cause sympathetic stimulation, leading to increased levels of catecholamine, resulting in alteration in vascular tone. Hypertensive response during exercise testing can cause abnormal consequences, resulting in false positive results.CasesWe present the cases of two patients experiencing apical and basal akinesis during exercise stress echocardiography, in whom normal wall motion response was observed on subsequent pharmacologic stress testing. The first patient developed transient left ventricular (LV) apical akinesis during exercise stress echocardiography. Due to high suspicion that this abnormality might be secondary to hypertensive response, pharmacologic stress testing was performed after three days, which was completely normal and showed no such wall motion abnormality. Qualitative assessment of myocardial perfusion using contrast was also performed, which showed good myocardial blood flow, indicating low probability for significant obstructive coronary artery disease. The second patient developed LV basal akinesis as a result of hypertensive response during exercise testing. Coronary angiogram was not performed in either patient due to low suspicion for coronary artery disease, and subsequently negative stress studies.ResultsTransient stress induced cardiomyopathy can develop secondary to hypertensive response during exercise stress testing.ConclusionThese cases provide supporting evidence to the hyper-sympathetic theory of left ventricular ballooning syndrome.

Mitral valve replacement and Takotsubo syndrome

Athanasiou et al. [1] should be commended for their seminal review on evidence synthesis and critical reappraisal of surgical techniques of preservation of mitral subvalvar apparatus. However, when Lillehei and colleagues in the early 1960s had proposed the chordal-sparing technique of mitral valve replacement (MVR), the entity of Takotsubo syndrome had not been described. Nearly 30 years later, Satoh et al. [2], Dote and colleagues [3] from Japan described in 1990 and 1991 this novel syndrome, characterized by transient reversible left ventricular (LV) dysfunction in the absence of coronary artery disease, with chest pain, electrocardiographic changes mimicking acute anterior myocardial infarction, but only minimal release of myocardial enzymes. Left ventriculograms revealedapeculiar shapeof theLVresembling aTakotsubo [the type of bottle with a round bottom and narrow neck — used in Japan for trapping octopus]. The syndrome is also known as acute left ventricular ballooning, transient apical ballooning, ampulla cardiomyopathy and because stress has been implicated in its pathophysiology. Human stress cardiomyopathy or broken-heart syndrome. We have earlier described the occurrence of Takotsubo syndrome in a patient after mitral valve replacement [4]. Diagnostic criteria for Takotsubo syndrome, viz. (a) new electrocardiographic abnormalities; either STelevations or T wave inversion, (b) absence of obstructive coronary artery disease, and (c) transient akinesia or dyskinesia of the left ventricle, etc. have been described [5]. Despite the characteristic, near pathognomonic pattern of LV wall motion abnormalities and the typical course of the syndrome, the clinician needs to differentiate it from three

Catecholamines May Play an Important Role in the Pathogenesis of Transient Mid- and Basal Ventricular Ballooning Syndrome

The exact pathogenesis of transient mid- and basal ventricular ballooning, a new variant of transient left ventricular (LV) ballooning, remains unknown. We report two cases of transient mid- and basal ventricular ballooning associated with catecholamines. These cases suggest that catecholamine-mediated myocardial dysfunction might be a potential mechanism of this syndrome.

Apical Ballooning Syndrome or Takotsubo Syndrome: A Novel Cardiac Syndrome

Apical Ballooning Syndrome or Takotsubo Syndrome: A Novel Cardiac Syndrome

Takotsubo cardiomyopathy (left ventricular ballooning syndrome) induced during dobutamine stress echocardiography

A 75-year-old woman presented with left ventricular apical ballooning syndrome mimicking acute anterior myocardial infarction. She had a long history of chest tightness and was undergoing a contrast stress echocardiogram because of frequent re-admissions with chest pain, all with normal ECGs and troponins. A standard dobutamine/atropine protocol had been used. The patient developed central crushing chest pain, marked ST elevation, transient slowing of heart rate and left ventricular apical ballooning. She was admitted to the coronary care unit and received thrombolysis. Echocardiography showed no mitral regurgitation, normal pulmonary artery systolic pressure and no intraventricular gradient. Immediate troponin T was significantly raised and peaked at 6 h. The patient underwent coronary angiography the next day. This showed systolic left ventricular apical ballooning and no coronary lesions or vasospasm. A further contrast echo 2 weeks later showed complete resolution of the wall motion abnormalities. Left ventricular apical ballooning or takotsubo syndrome can lead to cardiogenic shock but has a favourable prognosis compared to myocardial infarction. This patient was noted to be unusually anxious about having a stress echocardiogram and mental stress might be a precipitating factor, furthermore, this response during dobutamine stress echocardiography favours a catecholamine related disease mechanism.

The clinical features of transient left ventricular nonapical ballooning syndrome: Comparison with apical ballooning syndrome

Recently, several cases of atypical left ventricular (LV) ballooning syndrome without involvement of the LV apex have been reported. However, there has been no assessment of the clinical features of this novel presentation or comparison with the typical transient LV apical ballooning syndrome. We evaluated 47 patients diagnosed with transient LV ballooning syndrome. The diagnostic criteria were (1) transient akinesia/dyskinesia beyond a single major coronary artery vascular distribution, (2) absence of significant coronary artery disease on coronary angiograms, and (3) new electrocardiographic changes. Thirty-one patients showed classic LV apical ballooning, and 16 showed atypical LV ballooning without involvement of the LV apex (nonapical ballooning). Clinical presentations and inhospital courses of illness were mostly similar among patients with nonapical ballooning (group NA) and patients with apical ballooning (group A). However, on admission, there were fewer patients with cardiogenic shock or pulmonary edema in group NA than in group A (19% vs 48%, P = .048). Group NA patients were relatively younger than group A patients (median ages 58 vs 70 years, P = .02), and fewer patients had coronary risk factors in group NA than in group A (38% vs 77%, P = .01). On electrocardiogram, T-wave inversion was noted less frequently in the NA group than in the A group (69% vs 97%, P = .01). Transient LV nonapical ballooning syndrome and classic LV apical ballooning syndrome may be different manifestations of a single syndrome. They appear to have differences in the severity of heart failure, in patient characteristics, and in electrocardiographic change.

Atypical Transient Left Ventricular Ballooning Without Involvement of Apical Segment

Recently, the Mayo Clinic proposed criteria for the clinical diagnosis of the syndrome of left ventricular transient apical ballooning. This syndrome consists of the acute onset of transient, extensive akinesia of the apical and middle portions of the left ventricle without significant stenosis evident on the coronary angiogram, accompanied by chest symptoms, ECG changes, and limited release of cardiac markers disproportionate …

Cardiomiopatia de Takotsubo: uma causa rara de choque cardiogênico simulando infarto agudo do miocárdio

Takotsubo Cardiomiopathy is a rare cause of acute left ventricular aneurysm, in the absence of coronariopathy, only recently described in world literature. Symptoms may be similar to those from acute myocardial infarction with typical thoracic pain. The image of dumbbell or Takotsubo (a device used in Japan to capture octopus) suggestive ventricular ballooning is characteristic of that new syndrome and there is usually the disappearing of dyskinetic movement up to the 18th day from the beginning of the symptoms, in average.