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Siroya HL, Uppar AM, Madhugiri VS, Devi BI. Heartbroken Child: A Rare Case Report of Neurogenic Pulmonary Edema and Takotsubo Cardiomyopathy following Recurrent Medulloblastoma Excision with Possible Aetio-Patho-Bio-Physiological Mechanisms. Pediatr Neurosurg 2022; 57:279-286. [PMID: 35508116 DOI: 10.1159/000524896] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 04/03/2022] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Takotsubo (Japanese fishing pot for trapping octopus) cardiomyopathy is a rare phenomenon of acute coronary syndrome presenting usually with the presence of transient apical ballooning of the left ventricle in the absence of obstructive coronary artery disease. It is mainly seen in women of older age secondary to emotional, physical, or psychological stress. In age less than 18 years, it is mainly seen in adolescents suffering from psychiatric disorders and substance abuse. In children, it is rarely described. CASE PRESENTATION We present here a peculiar case of a 12-year-old child with neurogenic pulmonary oedema and takotsubo cardiomyopathy syndrome after surgery for recurrent medulloblastoma. Also, management challenges are discussed. DISCUSSION/CONCLUSION Takotsubo cardiomyopathy is not just a classical or inverted type but indeed a spectrum. It can be seen in any case, be it a child or adult secondary to handling or injury to the ponto-medullary junction, rostral pons, or dorsolateral medulla. The density and distribution of beta-adrenergic receptors may be different in children and adults which needs further research. Prognosis is usually excellent across all ages.
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Affiliation(s)
| | - Alok Mohan Uppar
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, NIMHANS, Bengaluru, India
| | - Venkatesh S Madhugiri
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, NIMHANS, Bengaluru, India
| | - Bhagavatula Indira Devi
- Department of Neurosurgery, National Institute of Mental Health and Neuro Sciences, NIMHANS, Bengaluru, India
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Meijs AC, Snel M, Corssmit EPM. Pheochromocytoma/paraganglioma crisis: case series from a tertiary referral center for pheochromocytomas and paragangliomas. Hormones (Athens) 2021; 20:395-403. [PMID: 33575936 PMCID: PMC8110488 DOI: 10.1007/s42000-021-00274-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 01/25/2021] [Indexed: 12/22/2022]
Abstract
Pheochromocytoma/paraganglioma (PPGL)-induced catecholamine crisis is a rare endocrine emergency leading to life-threatening hemodynamic instability causing end-organ damage or dysfunction. As it is associated with a significant mortality rate of approximately 15%, recognizing the signs and symptoms and making the appropriate diagnosis are critical. For this purpose, we report the clinical course of the crisis in four out of a total of six patients with a PPGL crisis from a cohort of 199 PPGL patients of a single tertiary referral center for PPGL patients in the Netherlands diagnosed between 2002 and 2020. Successful treatment of a PPGL crisis demands prompt diagnosis, vigorous pharmacological therapy, and emergency tumor removal if the patient continues to deteriorate.
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Affiliation(s)
- Anouk C Meijs
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands.
| | - Marieke Snel
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
| | - Eleonora P M Corssmit
- Department of Medicine, Division of Endocrinology, Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
- Center for Endocrine Tumors Leiden (CETL), Leiden University Medical Center, Albinusdreef 2, 2333 ZA, Leiden, The Netherlands
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Jiang X, Zhang W, Fang Q. Pheochromocytoma-related cardiomyopathy presenting as acute myocardial infarction: A case report. Medicine (Baltimore) 2021; 100:e24984. [PMID: 33725969 PMCID: PMC7982151 DOI: 10.1097/md.0000000000024984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/11/2021] [Indexed: 01/05/2023] Open
Abstract
INTRODUCTION Pheochromocytoma (PHEO)-related cardiomyopathy is a rare condition in which release of a large amount of catecholamines leads to severe vasoconstriction, coronary vasospasm, myocardial ischemia, injury, and necrosis. Its clinical manifestations can be similar to those of acute coronary syndrome. PATIENT CONCERNS A 63-year-old woman was diagnosed with acute non-ST segment elevation myocardial infarction following chest pain for 8 hours. The results of coronary angiography were normal. The patient developed dyspnea, cough with frothy pink sputum, paroxysmal sweating, arrhythmia, and blood pressure fluctuation, and was transferred to the intensive care unit for monitoring and treatment. DIAGNOSIS PHEO, catecholamine cardiomyopathy (CICMP). INTERVENTION After monitoring the pulse index continuous cardiac output and treatment with α and β adrenergic receptor blockers for 18 days, laparoscopic resection of the left adrenal mass was performed. OUTCOMES The patient's condition improved and she was discharged 31 days after admission. Outpatient follow-up examinations 1 month and 1 year later did not show recurrence. LESSONS PHEO can cause CICMP, the manifestations of which are partly similar to those of takotsubo cardiomyopathy (TTC). Once the patient's condition stabilizes, surgery should be considered. Fluid management is necessary, and agents such as α and β adrenergic receptor blockers should be administered.
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Affiliation(s)
- Xuandong Jiang
- Intensive Care Unit, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou
- Intensive Care Unit, Dongyang People's Hospital, Dongyang, Zhejiang, PR China
| | - Weimin Zhang
- Intensive Care Unit, Dongyang People's Hospital, Dongyang, Zhejiang, PR China
| | - Qiang Fang
- Intensive Care Unit, The First Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou
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Wannachalee T, Chunharojrith P. Safety of preoperative carvedilol in a patient with recent atenolol-induced pheochromocytoma crisis and cardiomyopathy: A case report. Ann Med Surg (Lond) 2020; 60:360-364. [PMID: 33224491 PMCID: PMC7666317 DOI: 10.1016/j.amsu.2020.11.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Revised: 11/01/2020] [Accepted: 11/01/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction Beta-adrenergic blockade without adequate alpha blockade is an established trigger of pheochromocytoma crisis (PC). Carvedilol is a nonselective beta-adrenergic and alpha 1-adrenergic blocking agent, and its use for preoperative preparation of pheochromocytoma patients with prior cardiomyopathy secondary to PC resulting from unopposed beta-blocker therapy has never been reported. Case presentation A 48-year-old woman was admitted to the Urology Department for evaluation of a huge right upper abdominal mass. She developed hypertensive crisis with acute pulmonary edema resulting in respiratory failure after administration of atenolol to treat hypertension and tachycardia. Transthoracic echocardiogram revealed global hypokinesia. The patient was managed with intravenous nicardipine, furosemide, and prazosin because of the clinical suspicion of pheochromocytoma that was subsequently confirmed by elevated plasma and urine catecholamine levels. Within 3 days of alpha-adrenergic blockers treatment, there was rapid amelioration of hypertension and pulmonary congestion, as well as normalization of left ventricular function by echocardiography. However, tachycardia persisted after 1 month of adequate alpha-adrenergic blockade. Given the benefit of beta-adrenergic blockers in patients with systolic dysfunction, we slowly titrated carvedilol while carefully monitoring the patient's condition in the intensive care unit. Tachycardia was controlled without inducing PC. Surgical resection was successful without perioperative complications. Conclusion Clinicians should be cautious when prescribing beta-adrenergic blocker in patients with hypertension and upper quadrant mass of unknown etiology. The mass may be pheochromocytoma. Preoperative use of carvedilol after sufficient alpha-adrenergic blockade for control of tachycardia in a patient with prior cardiomyopathy associated with atenolol-induced PC is safe and effective. Beta-adrenergic blocker should be used cautiously in patients with hypertension and upper quadrant mass. The mainstay of treatment for pheochromocytoma crisis is adequate alpha-adrenergic blockade. Preoperative use of carvedilol after alpha-adrenergic blockade in recent pheochromocytoma crisis is safe.
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Affiliation(s)
| | - Paweena Chunharojrith
- Corresponding author. Division of Endocrinology and Metabolism, Department of Medicine, Faculty of Medicine Siriraj Hospital, Asadang Building 8th Floor, Siriraj Hospital, 2 Prannok Road, Bangkok Noi, Bangkok, 10700, Thailand.
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Abstract
BACKGROUND AND PURPOSE Takotsubo cardiomyopathy (TCM), first reported by Japanese doctors, has gained an overall acknowledgment as an independent malady of international attention. It resembles the presentation of an acute myocardial infarction but lacks ischemic myocardial tissue. The objective of this article is to review the physiology, diagnostics, treatment, and complications of TCM and report a case study of a patient who developed TCM. METHODS Observation through direct patient care allowed for data collection of this unique medical phenomenon. Supporting information was obtained via investigation of scholarly articles on TCM over the past 10 years. CONCLUSIONS Although TCM is usually transient, it is important to quickly differentiate TCM from other more serious medical conditions, such as myocardial infarction, pulmonary embolism, and pheochromocytoma. Typical diagnostic workup includes electrocardiography, cardiac biomarkers, and echocardiography or coronary angiography. Complications include cardiogenic shock, left ventricular wall rupture, and life-threatening arrhythmias. IMPLICATIONS FOR PRACTICE The advanced practice nurse (APN) is instrumental in differentiating between TCM versus acute myocardial infarction, heart failure, pulmonary edema, dynamic outflow obstruction, and cardiogenic shock. Because of these possible acute and critical presentations, prompt recognition and intervention for patients with TCM are priorities for nurse practitioners.
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Chow LTC, Chow MBCY. Coronary artery myointimal dysplasia in patients with pheochromocytoma-possible causal relationship: pathophysiology and clinical implication with reference to Takotsubo cardiomyopathy and spontaneous coronary dissection. Cardiovasc Pathol 2018; 37:45-53. [PMID: 30342321 DOI: 10.1016/j.carpath.2018.10.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Revised: 08/25/2018] [Accepted: 10/01/2018] [Indexed: 02/07/2023] Open
Abstract
Myocardial damage in catecholamine cardiomyopathy, characterized by patchy myocyte necrosis commonly with contraction band appearances, interstitial fibrosis, and varying degrees of inflammatory infiltrates, has been well documented. However, coronary vascular pathology has not been recognized. Autopsy of a 43-year-old housewife who died of acute apical anteroseptal myocardial infarction revealed the incidental finding of a left adrenal pheochromocytoma. The epicardial and intramyocardial median- and small-sized coronary arteries exhibited myointimal dysplasia in the form of fibroblastic proliferation in the intima and media, resulting in thickened dysplastic vessels with marked luminal narrowing, occasionally leading to near-total occlusion. The distal left anterior descending artery showed features of recanalization after prior embolic occlusion. The density and severity of vascular involvement revealed a decreasing gradient from apical to basal region, mainly affecting the left ventricle, but the proximal coronary arteries were minimally affected. Myointimal dysplasia was not seen in control cases of hypertensive heart, and despite its presence in hearts with hypertrophic cardiomyopathy, it lacked the distinctive pattern of distribution and the epicardial vessels are uninvolved. Myointimal dysplasia probably results from reactive fibroplasia in response to the vasoconstrictive effect of circulating or local neurosecretory catecholamine and appears crucial in the pathogenesis of various types of catecholamine cardiomyopathy, including Takotsubo or stress cardiomyopathy. Together with the direct catecholamine cardiotoxicity, they result in diffuse microscopic ischemic necrosis and fibrosis. Depending on the type of catecholamine overproduction and action, together with the characteristic anatomic distribution and density of the various types of adrenergic receptors in the ventricles, different regions of the heart are variously affected so that different patterns of ventricular dysfunction are produced, with the subsequent angiographic appearances ranging from apical through midventricular to basal ballooning. Additional complications from the myointimal dysplasia include spontaneous coronary dissection, acute myocardial infarction, and superimposed thrombus formation in the dysplastic vessels and dyskinetic ventricle, with the risk of further damage from embolic events.
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Y-Hassan S, Tornvall P. Epidemiology, pathogenesis, and management of takotsubo syndrome. Clin Auton Res 2017; 28:53-65. [PMID: 28917022 PMCID: PMC5805795 DOI: 10.1007/s10286-017-0465-z] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 08/31/2017] [Indexed: 12/14/2022]
Abstract
Takotsubo syndrome is a recently recognized acute cardiac disease entity with a clinical presentation resembling that of an acute coronary syndrome. The typical takotsubo syndrome patient has a unique circumferential left (bi-) ventricular contraction abnormality profile that extends beyond a coronary artery supply territory and appears to follow the anatomical cardiac sympathetic innervation. The syndrome predominantly affects postmenopausal women and is often preceded by emotional or physical stress. Patients with predisposing factors such as malignancy and other chronic comorbidities are more prone to suffer from takotsubo syndrome. The pathogenesis of takotsubo syndrome is elusive. Several pathophysiological mechanisms involving myocardial ischemia (multivessel coronary artery spasm, microvascular dysfunction, aborted myocardial infarction), left ventricular outlet tract obstruction, blood-borne catecholamine myocardial toxicity, epinephrine-induced switch in signal trafficking, and autonomic nervous system dysfunction have been proposed. The syndrome is usually reversible; nevertheless, during the acute stage, a substantial number of patients develop severe complications such as arrhythmias, heart failure including pulmonary edema and cardiogenic shock, thromboembolism, cardiac arrest, and rupture. Treatment of precipitating factors, predisposing diseases, and complications is fundamental during the acute stage of the disease. The epidemiology, pathogenesis, and management of takotsubo syndrome are reviewed in this paper.
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Affiliation(s)
- Shams Y-Hassan
- Department of Cardiology, Karolinska Institutet at Karolinska University Hospital, Solna, Sweden
| | - Per Tornvall
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Sjukhusbacken 10, 118 83, Stockholm, Sweden.
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Extracorporeal Membrane Oxygenation for Treatment of Acute Inverted Takotsubo-Like Cardiomyopathy From Hemorrhagic Pheochromocytoma in Late Pregnancy. ACTA ACUST UNITED AC 2017; 7:196-199. [PMID: 27607406 DOI: 10.1213/xaa.0000000000000383] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We describe the first case of a pregnant woman presenting with an acute inverted takotsubo-like cardiomyopathy caused by a postpartum diagnosed hemorrhagic pheochromocytoma, successfully treated with percutaneous venoarterial extracorporeal membrane oxygenation (va-ECMO). During admission, an emergency cesarean delivery had to be performed. The fetus needed resuscitation for 5 minutes. The mother was successfully resuscitated and treated with percutaneous va-ECMO for 7 days. Despite advances in diagnostic techniques during the past decade, in many cases, pheochromocytoma in pregnancy is still missed. This results in a maternal and fetal mortality rate of up to 30% in both.
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Hemorrhagic pheochromocytoma presenting as severe hypertension with myocardial infarction. ANNALES D'ENDOCRINOLOGIE 2016; 78:54-56. [PMID: 27989549 DOI: 10.1016/j.ando.2016.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/12/2016] [Revised: 10/08/2016] [Accepted: 10/27/2016] [Indexed: 01/29/2023]
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Y-Hassan S, De Palma R. Contemporary review on the pathogenesis of takotsubo syndrome: The heart shedding tears: Norepinephrine churn and foam at the cardiac sympathetic nerve terminals. Int J Cardiol 2016; 228:528-536. [PMID: 27875730 DOI: 10.1016/j.ijcard.2016.11.086] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2016] [Accepted: 11/06/2016] [Indexed: 12/14/2022]
Abstract
Takotsubo syndrome (TS), an increasingly recognized acute cardiac disease entity, is characterized by a unique pattern of circumferential and typically regional left ventricular wall motion abnormality resulting in a conspicuous transient ballooning of the left ventricle during systole. The mechanism of the disease remains elusive. However, the sudden onset of acute myocardial stunning in a systematic pattern extending beyond a coronary artery territory; the history of a preceding emotional or physical stress factor in two thirds of cases; the signs of sympathetic denervation at the regions of left ventricular dysfunction on sympathetic scintigraphy; the finding of myocardial edema and other signs consistent with (catecholamine-induced) myocarditis shown by cardiac magnetic resonance imaging; and the contraction band necrosis on histopathological examination all argue strongly for the involvement of the cardiac sympathetic nervous system in the pathogenesis of TS. In this narrative review, extensive evidence in support of local cardiac sympathetic nerve hyperactivation, disruption and norepinephrine spillover causing TS in predisposed patients is provided.
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Affiliation(s)
- Shams Y-Hassan
- Karolinska Institute at Karolinska University Hospital, Department of Cardiology, Sweden.
| | - Rodney De Palma
- Karolinska Institute at Karolinska University Hospital, Department of Cardiology, Sweden
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Lopez Chiriboga AS, Yoon JW, Freeman WD, Odunukan OW, Cheshire WP. Takotsubo cardiomyopathy in the setting of acute hydrocephalus secondary to neurocysticercosis. Clin Auton Res 2016; 26:235-41. [PMID: 26951133 DOI: 10.1007/s10286-016-0348-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 02/02/2016] [Indexed: 01/21/2023]
Abstract
We report the case of a 45-year-old male who presented with transient neurogenic stunned myocardium, or takotsubo cardiomyopathy, secondary to acute hydrocephalus caused by obstruction of the third ventricle by neurocysticercosis.
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Affiliation(s)
- A S Lopez Chiriboga
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL, 32224, USA.
| | - J W Yoon
- Department of Neurosurgery, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL, 32224, USA
| | - W D Freeman
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL, 32224, USA
| | - O W Odunukan
- Department of Cardiology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL, 32224, USA
| | - W P Cheshire
- Department of Neurology, Mayo Clinic, 4500 San Pablo Rd., Jacksonville, FL, 32224, USA
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Batisse-Lignier M, Pereira B, Motreff P, Pierrard R, Burnot C, Vorilhon C, Maqdasy S, Roche B, Desbiez F, Clerfond G, Citron B, Lusson JR, Tauveron I, Eschalier R. Acute and Chronic Pheochromocytoma-Induced Cardiomyopathies: Different Prognoses?: A Systematic Analytical Review. Medicine (Baltimore) 2015; 94:e2198. [PMID: 26683930 PMCID: PMC5058902 DOI: 10.1097/md.0000000000002198] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Pheochromocytoma and paraganglioma (PPG) are rare and late-diagnosed catecholamine secreting tumors, which may be associated with unrecognized and/or severe cardiomyopathies. We performed a computer-assisted systematic search of the electronic Medline databases using the MESH terms "myocarditis," "myocardial infarction," "Takotsubo," "stress cardiomyopathy," "cardiogenic shock", or "dilated cardiomyopathy," and "pheochromocytoma" or "paraganglioma" from 1961 to August 2012. All detailed case reports of cardiomyopathy due to a PPG, without coronary stenosis, and revealed by acute symptoms were included and analyzed. A total of 145 cases reports were collected (49 Takotsubo Cardiomyopathies [TTC] and 96 other Catecholamine Cardiomyopathies [CC]). At initial presentation, prevalence of high blood pressure (87.7%), chest pain (49.0%), headaches (47.6%), palpitations (46.9%), sweating (39.3%), and shock (51.0%) were comparable between CC and TTC. Acute pulmonary edema (58.3% vs 38.8%, P = 0.03) was more frequent in CC. There was no difference in proportion of patients with severe left ventricular systolic dysfunction (LV Ejection Fraction [LVEF] < 30%) at initial presentation between both groups (P = 0.15). LVEF recovery before (64.9% vs 40.8%, P = 0.005) and after surgical resection (97.7% vs 73.3%, P = 0.001) was higher in the TTC group. Death occurred in 11 cases (7.6%). In multivariate analysis, only TTC was associated with a better LV recovery (0.15 [0.03-0.67], P = 0.03). Pheochromocytoma and paraganglioma can lead to different cardiomyopathies with the same brutal and life-threatening initial clinical presentation but with a different recovery rate. Diagnosis of unexplained dilated cardiomyopathy or TTC should lead clinicians to a specific search for PPG.
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Affiliation(s)
- Marie Batisse-Lignier
- From the CHU Clermont-Ferrand, Endocrinology Department, Clermont-Ferrand, France (MB-L, CB, SM, BR, FD, IT); CNRS UMR 6293, Inserm GReD, Clermont-Ferrand, France (MB-L, SM, IT); CHU Clermont-Ferrand, Biostatistics unit (Clinical Research and Innovation Direction), Clermont-Ferrand, France (BP); and Clermont Université, Université d'Auvergne, Cardio Vascular Interventional Therapy and Imaging (CaVITI), Image Science for Interventional Techniques (ISIT), UMR6284, and CHU Clermont-Ferrand, Cardiology Department, Clermont-Ferrand, France (PM, RP, CV, GC, BC, J-RL, RE)
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Mugnai G, Pasqualin G, Prati D, Menegatti G, Vassanelli C. Recurrent multiform Takotsubo cardiomyopathy in a patient with epilepsy: Broken heart or brain? Int J Cardiol 2015; 201:332-5. [DOI: 10.1016/j.ijcard.2014.11.212] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2014] [Accepted: 11/26/2014] [Indexed: 11/25/2022]
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Dual Diagnostic Role of 123I-MIBG Scintigraphy in Inverted-Takotsubo Pattern Cardiomyopathy. Clin Nucl Med 2015; 40:816-8. [DOI: 10.1097/rlu.0000000000000864] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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15
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Tagawa M, Nanba H, Suzuki H, Nakamura Y, Uchiyama H, Ochiai S, Terunuma M, Yahata K, Minamino T. Ventricular Rhythm and Hypotension in a Patient with Pheochromocytoma-induced Myocardial Damage and Reverse Takotsubo Cardiomyopathy. Intern Med 2015; 54:2343-9. [PMID: 26370859 DOI: 10.2169/internalmedicine.54.4732] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 33-year-old woman experienced near-syncope at a hospital. Electrocardiography revealed an intermittent ventricular rhythm. The echocardiogram at admission indicated mild hypokinesis and severe diffuse hypokinesis with reverse takotsubo cardiomyopathy on the following day. The patient experienced abdominal pain on the admission day, and computed tomography identified a large left adrenal mass. Her catecholamine levels increased remarkably on the third day. The wall motion improved on the twelfth day. The tumor was successfully resected and the patient was diagnosed with an ectopic pheochromocytoma. The ventricular rhythm with myocardial damage and hypotension induced by the reverse takotsubo cardiomyopathy masked the characteristic symptoms of pheochromocytoma.
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Affiliation(s)
- Minoru Tagawa
- Department of Cardiology, Nagaoka Chuo General Hospital, Japan
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Pogorzelski R, Toutounchi S, Krajewska E, Fiszer P, Łykowski M, Zapała Ł, Szostek M, Jakuczun W, Pachucki J, Skórski M. The effect of surgical treatment of phaeochromocytoma on concomitant arterial hypertension and diabetes mellitus in a single-centre retrospective study. Cent European J Urol 2014; 67:361-5. [PMID: 25667755 PMCID: PMC4310896 DOI: 10.5173/ceju.2014.04.art9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Revised: 08/26/2014] [Accepted: 09/01/2014] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Phaeochromocytoma is one of the numerous causes of secondary hypertension. Furthermore, phaeochromocytoma may first present with type 2 diabetes mellitus. The objective of our study was to evaluate the effects of adrenalectomy on patient recovery with regards to normotension and well-controlled glycaemia. MATERIAL AND METHODS The retrospective analysis involved 67 patients with phaeochromocytoma operated between 2006 and mid-2012. The pre-operative diagnoses were made in the departments of internal medicine and endocrinology. Based on laboratory tests and diagnostic imaging, we were able to confirm the diagnosis of phaeochromocytoma in 42 (62.7%) patients. We verified the influence of adrenalectomy on the level of patient recovery, with regards to normotension and glycaemic control: arterial pressure and fasting glycaemia levels were obtained on the day of hospital discharge, at follow-up 3 months post-operatively and 1 year after surgical intervention. RESULTS Of the 67 patients operated for phaeochromocytoma, 48 (71.6%) were treated laparoscopically, whereas 19 (28.4%) underwent open adrenalectomy. Arterial hypertension was recorded in 53 (79.1%) cases. Furthermore, among this group, diabetes mellitus coexisted in 21 (31.3%) cases. Postoperatively, 70% of cases of arterial hypertension and 90% of type 2 diabetes mellitus were cured. Additionally, a high rate of patients reported a quantitative reduced use of antihypertensive medicines. CONCLUSIONS In the majority of patients, surgical treatment of symptomatic phaeochromocytoma leads to a regression of arterial hypertension, or a reduction of the number or doses of medicines taken in one's treatment, and glucose-intolerance symptoms.
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Affiliation(s)
- Ryszard Pogorzelski
- Department of General and Thoracic Surgery, Medical University of Warsaw, Poland
| | - Sadegh Toutounchi
- Department of General and Thoracic Surgery, Medical University of Warsaw, Poland
| | - Ewa Krajewska
- Department of General and Thoracic Surgery, Medical University of Warsaw, Poland
| | - Patryk Fiszer
- Department of General and Thoracic Surgery, Medical University of Warsaw, Poland
| | - Marcin Łykowski
- Department of General and Thoracic Surgery, Medical University of Warsaw, Poland
| | - Łukasz Zapała
- Department of Urology, Multidisciplinary Hospital Warsaw–Międzylesie, Poland
| | - Małgorzata Szostek
- Department of General and Thoracic Surgery, Medical University of Warsaw, Poland
| | - Wawrzyniec Jakuczun
- Department of General and Thoracic Surgery, Medical University of Warsaw, Poland
| | - Janusz Pachucki
- Department of Internal Medicine and Endocrinology, Medical University of Warsaw, Poland
| | - Maciej Skórski
- Department of General and Thoracic Surgery, Medical University of Warsaw, Poland
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Flam B, Broomé M, Frenckner B, Bränström R, Bell M. Pheochromocytoma-Induced Inverted Takotsubo-Like Cardiomyopathy Leading to Cardiogenic Shock Successfully Treated With Extracorporeal Membrane Oxygenation. J Intensive Care Med 2014; 30:365-72. [DOI: 10.1177/0885066614552992] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/13/2014] [Indexed: 01/27/2023]
Abstract
Pheochromocytoma classically displays a variety of rather benign symptoms, such as headache, palpitations, and sweating, although severe cardiac manifestations have been described. We report a case of pheochromocytoma-induced inverted takotsubo-like cardiomyopathy leading to shock and cardiac arrest successfully treated with extracorporeal membrane oxygenation (ECMO) as a bridge to pharmacological therapy and curative adrenalectomy. A previously healthy 46-year-old woman presented to the emergency department with abdominal pain, dyspnea, nausea, and vomiting. Clinical evaluation revealed cardiorespiratory failure with hypoxia and severe metabolic acidosis. Computed tomography (CT) scan showed pulmonary edema and a left adrenal mass. Transthoracic echocardiography (TTE) displayed severe left ventricular dysfunction with inverted takotsubo contractile pattern. Despite mechanical ventilation and inotropic and vasopressor support, asystolic cardiac arrest ensued. The patient was resuscitated using manual chest compressions followed by venoarterial ECMO. Repeated TTEs demonstrated resolution of the cardiomyopathy within a few days. Laboratory results indicated transient renal and hepatic dysfunction, and CT scan of the brain displayed occipital infarctions. Biochemical testing and radionuclide scintigraphy confirmed a pheochromocytoma. Pharmacological adrenergic blockade was instituted prior to delayed adrenalectomy after which the diagnosis was histopathologically verified. The patient recovered after rehabilitation. We conclude that pheochromocytoma should be considered in patients presenting with unexplained cardiovascular compromise, especially if they display (inverted) takotsubo contractile pattern. Timely, adequate management might involve ECMO as a bridge to pharmacological therapy and curative surgery.
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Affiliation(s)
- Benjamin Flam
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Michael Broomé
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Frenckner
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
- Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Division of Pediatric Surgery, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Robert Bränström
- Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
- Endocrine and Sarcoma Surgery Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Max Bell
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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18
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Regressive changes in phaeochromocytomas and paroxysmal hypertension. Open Med (Wars) 2014. [DOI: 10.2478/s11536-013-0308-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Abstract
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Abstract
First described in Japan over 2 decades ago, takotsubo cardiomyopathy (TTC) has emerged as a unique cardiomyopathy with world-wide recognition, mimicking acute coronary syndrome. In early TTC experience, typical patients were older women, with a triggering emotional event, ST-segment elevation, and apical ballooning left ventricular (LV) contraction pattern. However, TTC is now more heterogeneous, occurring in males and younger individuals, without ST-segment elevation, as a spontaneous event in the absence of a trigger, and with diverse LV contraction patterns. Furthermore, TTC is more common than initially thought, now constituting 10% of women with suspected acute coronary syndrome. TTC is also associated with a broader range of psychological or physical triggers, including presentation during outpatient medical evaluations or hospitalization for acute illness. Although TTC has been considered a benign condition, it now carries a small but important risk for adverse outcomes, including cardiac arrest in 5%. Hemodynamic instability requiring intervention with vasopressor drugs or intra-aortic balloon pump is necessary in 15% and in-hospital mortality is approximately 5%, largely because of refractory cardiogenic shock or irreversible major comorbid conditions. Although complete cardiac recovery usually occurs rapidly, post-hospital survival may be less than the general population of similar age, largely because of concomitant illnesses. TTC may reoccur in up to 10% of patients, but β-blocking drugs are not absolutely preventive for initial or subsequent events.
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Affiliation(s)
- Scott W Sharkey
- Minneapolis Heart Institute Foundation at Abbott Northwestern Hospital
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20
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Nishida J, Kouzu H, Hashimoto A, Fujito T, Kawamukai M, Mochizuki A, Muranaka A, Kokubu N, Shimoshige S, Yuda S, Hase M, Tsuchihashi K, Miura T. "Ballooning" patterns in takotsubo cardiomyopathy reflect different clinical backgrounds and outcomes: a BOREAS-TCM study. Heart Vessels 2014; 30:789-97. [PMID: 25059855 DOI: 10.1007/s00380-014-0548-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2014] [Accepted: 06/27/2014] [Indexed: 01/17/2023]
Abstract
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.
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Affiliation(s)
- Junichi Nishida
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Hidemichi Kouzu
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Akiyoshi Hashimoto
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Takefumi Fujito
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Mina Kawamukai
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Atsushi Mochizuki
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Atsuko Muranaka
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Nobuaki Kokubu
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Shinya Shimoshige
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Satoshi Yuda
- Department of Clinical Laboratory Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Mamoru Hase
- Department of Emergency Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Kazufumi Tsuchihashi
- Division of Health Care Administration and Management, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan
| | - Tetsuji Miura
- Department of Cardiovascular, Renal and Metabolic Medicine, Sapporo Medical University School of Medicine, South-1, West-16, Chuo-ku, Sapporo, 060-8543, Japan.
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21
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Madias JE. Coronary vasospasm is an unlikely cause of Takotsubo syndrome, although we should keep an open mind. Int J Cardiol 2014; 176:1-5. [PMID: 25043215 DOI: 10.1016/j.ijcard.2014.06.069] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/29/2014] [Indexed: 12/12/2022]
Abstract
This viewpoint pertains to the still elusive pathophysiology of the Takotsubo syndrome (TTS), maintaining the position that this affliction is not the result of coronary vasospasm (CV) involving one or more coronary arteries. Although CV has been rarely encountered in the acute stage of TTS, or elicited via provocative testing in the subacute stage of the disease, it does not appear to be the cause of TTS as shown by the bulk of the published relevant literature. The author provides some speculations to explain the spontaneous appearance of CV, or its artificial elicitation, in some patients with TTS. However while we are striving to unravel the pathophysiology of TTS, we should keep an open mind about a possible role for CV in the causation of TTS.
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Affiliation(s)
- John E Madias
- Icahn School of Medicine at Mount Sinai, New York, NY, United States; Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States.
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22
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Cho SK, Kim KH, Cho JY, Yoon HJ, Park HW, Hong YJ, Kim JH, Ahn Y, Jeong MH, Cho JG, Park JC. Pheochromocytoma as a rare hidden cause of inverted stress cardiomyopathy. J Cardiovasc Ultrasound 2014; 22:80-3. [PMID: 25031798 PMCID: PMC4096669 DOI: 10.4250/jcu.2014.22.2.80] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 09/26/2013] [Accepted: 05/15/2014] [Indexed: 11/22/2022] Open
Abstract
Stress cardiomyopathy (SCMP) is characterized by a transient left ventricular dysfunction associated with apical ballooning and compensatory hyperkinesias of the basal segments after emotional or physical stress, but inverted or mid-ventricular variants of SCMP have also been described. Although catecholamine excess has been suggested as a possible pathophysiologic mechanism of SCMP, the etiology of SCMP is still unknown. Here, we report a case of inverted type of SCMP with clinical presentation mimicking acute coronary syndromes. The cause or precipitating stressor was unclear initially, but pheochromocytoma has been demonstrated as a cause of SCMP during clinical follow-up at out-patient clinic in the present case. Catecholamine-producing tumors should be included in the evaluation or management of SCMP, even though initial clinical manifestations are not suggestive for pheochromocytoma.
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Affiliation(s)
- Soo Kyung Cho
- Department of Internal Medicine, Christian Hospital, Gwangju, Korea
| | - Kye Hun Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Jae Yeong Cho
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hyun Ju Yoon
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Hyung Wook Park
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Young Joon Hong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Ju Han Kim
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Youngkeun Ahn
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Myung Ho Jeong
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Jeong Gwan Cho
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
| | - Jong Chun Park
- Department of Cardiology, Chonnam National University Hospital, Gwangju, Korea
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23
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Yalcinkaya E, Bugan B, Celik M, Yildirim E, Gursoy E. Cardiomyopathies: the value of cardiac magnetic resonance imaging. Med Princ Pract 2014; 23:191. [PMID: 24280689 PMCID: PMC5586852 DOI: 10.1159/000356379] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2013] [Accepted: 10/09/2013] [Indexed: 02/04/2023] Open
Affiliation(s)
- Emre Yalcinkaya
- Department of Cardiology, Gulhane Military Medical Faculty, Ankara, Turkey
- *Emre Yalcinkaya, GATA Etlik, TR-06018 Ankara (Turkey), E-Mail
| | - Baris Bugan
- Department of Cardiology, Malatya Army Hospital, Malatya, Turkey
| | - Murat Celik
- Department of Cardiology, Gulhane Military Medical Faculty, Ankara, Turkey
| | - Erkan Yildirim
- Department of Cardiology, Gulhane Military Medical Faculty, Ankara, Turkey
| | - Erol Gursoy
- Department of Cardiology, Gulhane Military Medical Faculty, Ankara, Turkey
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24
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Y-Hassan S. Acute cardiac sympathetic disruption in the pathogenesis of the takotsubo syndrome: a systematic review of the literature to date. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2013; 15:35-42. [PMID: 24140050 DOI: 10.1016/j.carrev.2013.09.008] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2013] [Revised: 09/09/2013] [Accepted: 09/13/2013] [Indexed: 12/25/2022]
Abstract
Takotsubo syndrome (TS), also known as broken heart syndrome and neurogenic stunned myocardium, is an acute cardiac disease entity characterized by a clinical picture mimicking that of an acute coronary syndrome. The pathogenesis of TS has not been established yet. Among the most often debated pathologic mechanisms of TS are as follows: first, multi-vessel coronary spasm; second, myocardial microvascular dysfunction; third, aborted myocardial infarction caused by transient thrombotic occlusion of a long wrap-around left anterior descending artery; fourth, left ventricular outflow tract obstruction; fifth, blood-borne catecholamine cardiac toxicity; and sixth, cardiac sympathetic disruption and norepinephrine seethe and spillover. The aim of this review is to provide a thorough analysis of the literature data coming mainly from the neurological literature and dealing with the pathogenesis of TS. Substantial evidence challenging the first five hypotheses and arguing in favor of the hypothesis that acute cardiac sympathetic eruption and norepinephrine seethe and spillover is causing TS in predisposed patients is presented.
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Affiliation(s)
- Shams Y-Hassan
- Department of Cardiology, Karolinska Institute at Karolinska University Hospital, Stockholm, Sweden.
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25
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26
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Katayama Y, Hifumi T, Inoue J, Koido Y. A case of Takotsubo cardiomyopathy induced by accidental hypothermia and diabetic ketoacidosis. BMJ Case Rep 2013; 2013:bcr-2012-008143. [PMID: 23559645 DOI: 10.1136/bcr-2012-008143] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Takotsubo cardiomyopathy is known to be triggered by some stress. We report the first case of Takotsubo cardiomyopathy induced by hypothermia and diabetic ketoacidosis (DKA). A 59-year-old woman was brought to our emergency department. Upon examination, she was found to be lethargic and disoriented. The body temperature was 30.9°C, blood pressure was 86/68 mm Hg, blood glucose level was 1018 mg/dl. Urinalysis revealed the presence of ketones and arterial blood gas analysis revealed pH 6.87. She was diagnosed with DKA and accidental hypothermia. An ECG demonstrated a J wave (V(4-5)) and ST-segment elevation (V(3-5)), and an ultrasound cardiogram revealed contractile failure of the left ventricular wall at the apex with hypercontraction of the basal segment. Coronary artery disease was ruled out by coronary angiography, and the diagnosis of Takotsubo cardiomyopathy was confirmed. Physicians should keep in mind that Takotsubo cardiomyopathy can be induced by accidental hypothermia and DKA.
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Affiliation(s)
- Yoichi Katayama
- Department of Emergency Medicine, Sapporo Medical University Hospital, Sapporo City, Hokkaido, Japan.
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28
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The ace of spades: reverse takotsubo cardiomyopathy in the context of angiographic embolization of recurrent metastatic serotonin-positive neuroendocrine tumour of the pancreas. Case Rep Med 2013; 2013:793193. [PMID: 23476666 PMCID: PMC3580936 DOI: 10.1155/2013/793193] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2012] [Revised: 12/20/2012] [Accepted: 12/31/2012] [Indexed: 11/17/2022] Open
Abstract
A 62-year-old woman undergoing embolization of recurrent neuroendocrine tumor, positive for serotonin, developed chest pain and bradycardia with lateral ST-segment depression. Cardiac biomarkers were elevated, and echocardiography revealed akinesis of all basal segments with a normally contracting apex. The absence of flow-limiting coronary disease on angiography confirmed the presence of reverse Takotsubo cardiomyopathy. After optimal medical therapy for six weeks, left ventricular function returned to normal. Takotsubo cardiomyopathy has been described across a wide variety of hyperadrenergic states; the description of the reverse-type Takotsubo cardiomyopathy in the setting of embolization of recurrent neuroendocrine with serotonergic positivity tumour is novel.
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29
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Cardillo MT, Bona RD, Caroli A, Valentini AL, Biasucci LM. A case of unusual acute coronary syndrome. Am J Emerg Med 2013; 31:758.e1-2. [PMID: 23380113 DOI: 10.1016/j.ajem.2012.11.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Accepted: 11/17/2012] [Indexed: 10/27/2022] Open
Abstract
Pheochromocytoma is a rare tumor that usually develops ahead of the neuroectodermal chromaffin cells of the adrenal medulla, but it may arise anywhere within plexus of sympathetic adrenergic nerves. Headache, palpitations, tremor, excessive sweating, abdominal pain, and hypertensive paroxysm are the common clinical presentations of the tumor, but it has also been reported several cardiac symptoms.
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30
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Subramanyam S, Kreisberg RA. Pheochromocytoma: a cause of ST-segment elevation myocardial infarction, transient left ventricular dysfunction, and takotsubo cardiomyopathy. Endocr Pract 2013; 18:e77-80. [PMID: 22441003 DOI: 10.4158/ep11346.cr] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To report the case of a patient with a pheochromocytoma and apical left ventricular dysfunction that resolved after surgical resection of the pheochromocytoma, to review the effects of catecholamines on myocyte function and the concept that takotsubo cardiomyopathy (TC) is caused by excess catecholamines, and to illustrate the difficulty in the management of an acute coronary syndrome (ACS) during a hypertensive crisis attributable to a pheochromocytoma. METHODS We present the clinical history, physical findings, laboratory results, and imaging studies in a 60-year-old man with an ACS, TC, and an incidentaloma later diagnosed to be a pheochromocytoma. The association with TC and the pertinent literature are reviewed. RESULTS A 60-year-old man was suspected of having myocardial ischemia on the basis of symptoms of paroxysmal chest pain extending to the left shoulder, diaphoresis, ST-segment elevation on an electrocardiogram, and elevated serial levels of cardiac enzymes. Coronary angiography did not reveal substantial coronary artery obstruction but detected ballooning of the apical, anterior, and inferior cardiac walls, consistent with TC. He had a history of labile hypertension and palpitations of 3 months' duration. An adrenal mass detected on a prior computed tomographic scan and increased 24-hour urine catecholamine levels were consistent with a pheochromocytoma. Treatment with phenoxybenzamine was initiated, and he underwent a right adrenalectomy, which confirmed that the tumor was a pheochromocytoma and dramatically improved the patient's condition. CONCLUSION Pheochromocytomas manifest with labile blood pressures and should be considered in the differential diagnosis of ACS. This case also supports the concept that TC is caused by excess catecholamines.
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Affiliation(s)
- Sheela Subramanyam
- Department of Diabetes, Metabolism, Endocrinology and Internal Medicine, Baptist Health System, Birmingham, Alabama 35213, USA.
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31
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Contargyris C, Nee L, Saby C, Kerbaul F, Peytel E. Choc cardiogénique révélant un phéochromocytome traité par assistance circulatoire. ACTA ACUST UNITED AC 2012; 31:965-8. [DOI: 10.1016/j.annfar.2012.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 10/09/2012] [Indexed: 01/09/2023]
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32
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Regional wall motion abnormalities in patients with pheochromocytoma. Hypertens Res 2012; 35:1135. [DOI: 10.1038/hr.2012.149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Cheshire WP, Freeman R. Highlights in Clinical Autonomic Neuroscience: Latest discoveries from the octopus pot. Auton Neurosci 2012; 169:4-6. [DOI: 10.1016/j.autneu.2012.04.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Endomyocardial biopsy in a patient with hemorrhagic pheochromocytoma presenting as inverted Takotsubo cardiomyopathy. Heart Vessels 2012; 28:255-63. [PMID: 22476628 DOI: 10.1007/s00380-012-0247-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2011] [Accepted: 03/02/2012] [Indexed: 01/06/2023]
Abstract
A 29-year-old female patient presented with shock and dyspnea due to heart failure and pulmonary edema. Echocardiography indicated excessive contraction limited to the left ventricular apex and akinesis of the basal and middle ventricle, which were confirmed by emergency left ventriculography. The finding was diagnostic of inverted Takotsubo cardiomyopathy. An abdominal computed tomography scan showed a tumor in the left adrenal gland with a central low-density area, and the plasma and urinary catecholamines were strikingly elevated. Taken together, these findings suggested the presence of a hemorrhagic pheochromocytoma. A myocardial biopsy in the very acute stage on the day of admission revealed neutrophilic infiltration and contraction-band necrosis, which was indistinguishable from the previously reported pathology in the acute phase of idiopathic Takotsubo cardiomyopathy without pheochromocytoma. The diagnosis of pheochromocytoma in this case was confirmed 7 weeks later by surgical removal of the left adrenal gland with massive hemorrhage at the center of the pheochromocytoma. The marked similarity of the endomyocardial pathology between this case and cases with idiopathic Takotsubo cardiomyopathy strongly points to catecholamine excess as a common causality for Takotsubo cardiomyopathy with or without pheochromocytoma.
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Abstract
Stress-related cardiomyopathies can be observed in the four following situations: Takotsubo cardiomyopathy or apical ballooning syndrome; acute left ventricular dysfunction associated with subarachnoid hemorrhage; acute left ventricular dysfunction associated with pheochromocytoma and exogenous catecholamine administration; acute left ventricular dysfunction in the critically ill. Cardiac toxicity was mediated more by catecholamines released directly into the heart via neural connection than by those reaching the heart via the bloodstream. The mechanisms underlying the association between this generalized autonomic storm secondary to a life-threatening stress and myocardial toxicity are widely discussed. Takotsubo cardiomyopathy has been reported all over the world and has been acknowledged by the American Heart Association as a form of reversible cardiomyopathy. Four "Mayo Clinic" diagnostic criteria are required for the diagnosis of Takotsubo cardiomyopathy: 1) transient left ventricular wall motion abnormalities involving the apical and/or midventricular myocardial segments with wall motion abnormalities extending beyond a single epicardial coronary artery distribution; 2) absence of obstructive epicardial coronary artery disease that could be responsible for the observed wall motion abnormality; 3) ECG abnormalities, such as transient ST-segment elevation and/or diffuse T wave inversion associated with a slight troponin elevation; and 4) the lack of proven pheochromocytoma and myocarditis. ECG changes and LV dysfunction occur frequently following subarachnoid hemorrhage and ischemic stroke. This entity, referred as neurocardiogenic stunning, was called neurogenic stress-related cardiomyopathy. Stress-related cardiomyopathy has been reported in patients with pheochromocytoma and in patients receiving intravenous exogenous catecholamine administration. The role of a huge increase in endogenous and/or exogenous catecholamine level in critically ill patients (severe sepsis, post cardiac resuscitation, post tachycardia) to explain the onset of myocardial dysfunction was discussed. Further research is needed to understand this complex interaction between heart and brain and to identify risk factors and therapeutic and preventive strategies.
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Affiliation(s)
- Christian Richard
- AP-HP, Hôpital de Bicêtre, service de réanimation médicale, Le Kremlin-Bicêtre, F-94270 France.
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36
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Park JH, Kim KS, Sul JY, Shin SK, Kim JH, Lee JH, Choi SW, Jeong JO, Seong IW. Prevalence and patterns of left ventricular dysfunction in patients with pheochromocytoma. J Cardiovasc Ultrasound 2011; 19:76-82. [PMID: 21860721 PMCID: PMC3150700 DOI: 10.4250/jcu.2011.19.2.76] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2011] [Revised: 05/23/2011] [Accepted: 05/25/2011] [Indexed: 01/16/2023] Open
Abstract
Background Excessive catecholamine release in pheochromocytoma is known to cause transient reversible left ventricular (LV) dysfunction, such as in the case of pheochromocytoma-associated catecholamine cardiomyopathy. We investigated patterns of clinical presentation and incidence of LV dysfunction in patients with pheochromocytoma. Methods From January 2004 to April 2011, consecutive patients with pheochromocytoma were retrospectively studied with clinical symptoms, serum catecholamine profiles, and radiologic findings. Patterns of electrocardiography and echocardiography were also analyzed. Results During the study period, a total of 36 patients (21 males, 49.8 ± 15.8 years, range 14-81 years) with pheochromocytoma were included. In the electrocardiographic examinations, normal findings were the most common findings (19, 52.8%). LV hypertrophy in 12 cases (33.3%), sinus tachycardia in 3 (8.3%), ischemic pattern in 1 (2.8%) and supraventricular tachycardia in 1 (2.8%). Echocardiographic exam was done in 29 patients (80.6%). Eighteen patients (62.1%) showed normal finding, 8 (27.6%) revealed concentric LV hypertrophy with normal LV systolic function, and 3 (10.3%) demonstrate LV systolic dysfunction (LV ejection fraction < 50%). Three showed transient LV dysfunction (2 with inverted Takotsubo-type cardiomyopathy and 1 with a diffuse hypokinesia pattern). Common presenting symptoms in the 3 cases were new onset chest discomfort and dyspnea which were not common in the other patients. Their echocardiographic abnormalities were normalized with conventional treatment within 3 days. Conclusion Out of total 36 patients with pheochromocytoma, 3 showed transient LV systolic dysfunction (catecholamine cardiomyopathy). Pheochromocytoma should be included as one of possible causes of transient LV systolic dysfunction.
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Affiliation(s)
- Jae-Hyeong Park
- Division of Cardiology, Department of Internal Medicine, School of Medicine, Chungnam National University, Regional Cardiocerebrovascular Center, Chungnam National University Hospital, Daejeon, Korea
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Alsidawi S, Muth J, Wilkin J. Adderall induced inverted-Takotsubo cardiomyopathy. Catheter Cardiovasc Interv 2011; 78:910-3. [DOI: 10.1002/ccd.23036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2011] [Accepted: 01/29/2011] [Indexed: 11/08/2022]
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Takotsubo-like cardiomyopathy in pheochromocytoma. Int J Cardiol 2011; 153:241-8. [PMID: 21474192 DOI: 10.1016/j.ijcard.2011.03.027] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2010] [Revised: 03/03/2011] [Accepted: 03/11/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND Takotsubo Cardiomyopathy (TTC) is commonly triggered by acute illness, physical or emotional stress and has been associated with elevated catecholamine levels. TTC has also been associated with pheochromocytoma (TTC-pheo). METHODS We performed a computer assisted search of the electronic databases Medline, Scopus and Google Scholar from 1965 to January 2011. All case reports with reported TTC-pheo were selected and compared to a recent review by Gianni et al. which examined primary TTC (TTC-primary). STATISTICS Data analysis was performed using SPSS version 18. Chi-square test of Fisher's exact test was used as appropriate to compare categorical data. RESULTS 38 cases of TTC-pheo were retrieved from literature and compared to 254 cases of TTC-p. Chest pain was the most common presentation in both groups. The TTC-pheo patients were on average 18 years younger than patients with TTC-p (p<0.01). Only a minority of TTC-pheo patients presented with classical features of pheochromocytoma including hypertension (52.6%), headache (28.9%), palpitations (31.6 %), and diaphoresis (26.3%). In TTC-pheo complications rates were higher compared to TTC-p, including cardiogenic shock (34.2% vs. 4.2%, p<0.01) and heart failure (46.7% vs. 17.7%, p<0.01). Antecedent stressors were less common in TTC-pheo. About one-third of TTC-pheo patients presented with the inverted pattern, which compared to the apical pattern, was associated with higher complication rates, including, cardiogenic shock, heart failure, acute renal failure and arrhythmias. CONCLUSIONS Although rare, pheochromocytoma should be considered in the differential diagnosis of TTC especially in younger patients presenting without antecedent stressors and a high complication rate. The similarities in the clinical features and outcomes in patients with TTC-p and TTC-pheo point to a similar underlying cardiac pathophysiologic process at the time of the acute presentation.
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Mehta NK, Aurigemma G, Rafeq Z, Starobin O. Reverse takotsubo cardiomyopathy: after an episode of serotonin syndrome. Tex Heart Inst J 2011; 38:568-572. [PMID: 22163138 PMCID: PMC3231548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Stress-induced cardiomyopathy is characterized by transient left ventricular dysfunction, usually followed by complete resolution. It is precipitated by severe stress, and the most common variant (takotsubo) is marked by apical hypokinesis and ballooning with basal hyperkinesis. Serotonin syndrome is best understood as excess serotonergic activity in the central and peripheral nervous system. This imposes significant stress on the body. We report what we believe is the 1st case of serotonin syndrome as an indirect cause of stress-induced cardiomyopathy with a reverse takotsubo profile.
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Affiliation(s)
- Nishaki Kiran Mehta
- Department of Medicine, and Division of Cardiovascular Medicine, University of Massachusetts Medical School, Worcester, Massachusetts 01605, USA.
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