The clinical characteristics, laboratory parameters, electrocardiographic, and echocardiographic findings of reverse or inverted takotsubo cardiomyopathy: comparison with mid or apical variant

Stress in Focus: A Rare Case of Mid-Ventricular Takotsubo Cardiomyopathy Presenting as Cardiac Asthma

Mid-ventricular Takotsubo cardiomyopathy (TCM) is a variant of Takotsubo syndrome characterized by transient akinesis or dyskinesis of the mid-ventricular segments of the left ventricle, with sparing of the apical and basal segments. This differs from the typical apical form, which involves akinesis of the apical segments and hyperkinesis of the basal segments. Herein, we describe a unique case of mid-ventricular TCM presenting as cardiac asthma in a postmenopausal woman. Our patient reported a 2-day history of shortness of breath and intermittent wheezing that persisted even with respiratory treatment. Triage blood tests showed elevated troponin levels, and electrocardiogram was notable for septal Q waves, raising concern for acute coronary syndrome (ACS). Left heart catheterization revealed nonobstructive coronary artery disease, and ventriculography revealed mid-ventricular dyskinesia with a hypercontractile apex and base, consistent with mid-ventricular TCM. The ACS protocol was aborted, and the patient was managed conservatively with beta-blockers. Repeat echocardiogram at the 3-month follow-up showed recovered heart function, with no wall motion abnormalities.

Comparison of electrographic changes, clinical features and outcomes in different variants of Takotsubo syndrome

BACKGROUND

Dysfunction of the left ventricular (LV) apex (apical variant) is the most common form in Takotsubo syndrome (TS). Several less common non-apical variants have been described - mid-ventricular, basal and focal. We hypothesised that the clinical presentation, and electrocardiographic (ECG) findings may vary between apical and non-apical TS.

METHODS

We prospectively identified 194 consecutive patients with TS presenting to Middlemore Hospital, Auckland and obtained clinical, echocardiography, coronary angiography, and long-term follow-up data. ECGs at admission and Day 1 were compared.

RESULTS

Of 194 patients with TS, 168 (86.6%) had apical TS, and 26 (13.4%) non-apical TS (11 mid-ventricular TS, 5 basal TS, 10 focal TS). Apical TS patients had more significant LV systolic impairment (p = 0.001) and longer length of stay (p = 0.001). The extent of T-wave inversion (TWI) was similar for both groups on admission (p = 0.88). By Day 1 the extent of TWI was greater in apical TS group (median number of leads 5 vs. 1, p = 0.02). The change in QTc interval between admission and Day 1 was greater in apical TS group (29.7 ms vs. 2.77 ms, p < 0.001). Composite in-hospital complication rate was similar for both groups (13.7% vs. 15.4%, p = 0.77).

CONCLUSIONS

Compared with non-apical variants, apical TS patients develop more extensive TWI and greater QT prolongation on ECG, and more significant LV systolic impairment, but in-hospital complications were similar. Clinicians should be aware that there is a sub-group of TS patients who have non-apical regional wall motion abnormalities and who don't develop ECG changes typical of the more common apical variant.

Cardiovascular Magnetic Resonance Imaging in Myocardial Disease

Cardiovascular magnetic resonance (CMR) is the central non-invasive imaging investigation for the evaluation of myocardial disease. It is the well-established gold standard for measuring cardiac chamber volumes, systolic function, and left ventricular mass, and it brings unique information for therapeutic decisions. In addition, its tissue characterization capability, through T1, T2, and T2* mapping, as well as early and late gadolinium enhancement (LGE) sequences, allows to differentiate in many cases among ischemic, inflammatory, and infiltrative heart disease and permits the quantification of myocardial fibrosis, providing valuable diagnostic and prognostic information. This review aims to highlight the main CMR features of different cardiomyopathies.

An Extensive Review on Imaging Diagnosis Methods in Takotsubo Syndrome

Takotsubo Syndrome (TS) is an acute, reversible cardiac dysfunction, with complex, not entirely understood pathophysiology and heterogeneous clinical picture. Imaging methods each have a crucial role in the diagnosis, in-hospital management, short term and long term follow up. Coronary angiography needs to be performed, especially in the setting of a suspected acute coronary syndrome, in order to rule out coronary artery disease. Echocardiography plays a central role both in the acute and the chronic phase. It is the first imaging investigation performed in patients with TS, valuable to diagnose systolic dysfunction, the wall motion pattern and early complications. Cardiac magnetic resonance tissue characterization provides an essential role in the differential diagnosis of TS with other non-ischemic causes of systolic dysfunction. This review focuses on the imaging methods and the important part they play in the complex management of the disease.

Reverse Takotsubo Cardiomyopathy in a Critically Ill Patient in the ICU: A Case Report With Literature Review

Takotsubo, or stress cardiomyopathy (SC), is described as a transient systolic dysfunction of the apical segments of the left ventricle mainly triggered by emotional or physical stress resembling the presentation of an acute coronary syndrome in the absence of obstructive coronary artery disease. Reverse Takotsubo SC is a rare variant of SC that presents with basal ballooning instead of apical ballooning seen in classic SC. We present a case of a 74-year-old male who was admitted to the ICU with septic shock. Laboratory test results showed elevated troponin. An echocardiogram showed reduced cardiac contractility and relative hypokinesis of the basal and mid segments compared to the apical segments, consistent with reverse Takotsubo SC, which recovered after 10 days. It can happen in critically ill patients in the ICU secondary to severe sepsis and could contribute to hemodynamic worsening, affecting the final clinical outcomes.

Can Breaking Heroin Addiction Lead to a Broken Heart? A Case of Reverse Takotsubo Cardiomyopathy in a Patient With Heroin Withdrawal

Reverse takotsubo cardiomyopathy is triggered by emotional or physical stress and has a presentation similar to that of acute coronary syndrome. A 39-year-old woman with a history of heroin use disorder presented with intractable nausea, vomiting, and diarrhea. She was diagnosed with heroin withdrawal and started on buprenorphine-naloxone. On day 2 of her hospitalization, she developed chest heaviness and had an elevated troponin I level of 3.2 ng/mL (reference range, 0.015-0.045 ng/mL); electrocardiography showed new T-wave inversions in the anterior and inferior leads. Emergent coronary angiography showed patent coronary arteries, and left ventriculography showed basal hypokinesis and apical hyperkinesis, consistent with reverse takotsubo cardiomyopathy secondary to heroin withdrawal. She was started on antihypertensive agents, and her buprenorphine-naloxone dose was increased. At her 3-month follow-up visit, she reported no symptoms consistent with angina or heart failure. This appears to be the first report of heroin withdrawal causing reverse takotsubo cardiomyopathy. Awareness of this association can lead to earlier recognition and treatment of reverse takotsubo cardiomyopathy.

Car accident as a trigger for reverse takotsubo-like cardiomyopathy with paraganglioma: Case report and literature review

Paraganglioma (PGL), which may cause acute Takotsubo-like cardiomyopathy (TLC), is a rare neuroendocrine neoplasm derived from various body sites. TLC has been associated with excessive catecholamine secretion and shares the same cardiac presentation with Takotsubo cardiomyopathy (TTC). We present the case of a 58-year-old male who arrived at the hospital after a car accident, reporting symptoms of chest tightness, shortness of breath, and abdominal pain after a car accident. The patient was found to have elevated troponin and severely depressed left ventricular function. Echocardiography depicted a normal contracting apex with the rest of the left ventricle being hypokinetic. Coronary computed tomography (CT) angiogram revealed mild coronary artery disease. Abdominal CT further revealed a mass on the left side of the epigastric aorta, confirmed by autopsy as a PGL.

A Rare Case of Iatrogenic Inverted Stress Cardiomyopathy

We discuss a case of a 42-year-old female who was admitted for chronic intractable lower back pain requiring elective spinal surgery. Postoperatively, she experienced chest pressure and abdominal pain with a notable elevation in cardiac markers. A cardiac catheterization and left ventriculogram revealed normal coronary arteries and basal anterolateral hypokinesis, with the normal movement of the distal segment of the anterior wall. A rare variant of stress cardiomyopathy was diagnosed.

Paraganglioma-induced inverted takotsubo-like cardiomyopathy leading to cardiogenic shock successfully treated with extracorporeal membrane oxygenation

Paragangliomas are rare neuroendocrine tumors that originate in the chromaffin cells of the adrenal medulla or lymph nodes. Paragangliomas manifest in rare cases as catecholamine crisis, leading to heart failure, intracranial hemorrhage, renal failure, arrhythmias, pulmonary edema, or multisystem failure. Takotsubo cardiomyopathy is also called apical ballooning syndrome or stress cardiomyopathy. Left ventricular dysfunction with apical hyperkinesis and basilar and midventricular akinesis in the absence of coronary artery disease is highly suggestive of a variant of stress cardiomyopathy (inverted takotsubo cardiomyopathy). Herein, we report the case of a 69-year-old man with an unknown retroperitoneal paraganglioma who suffered from cardiogenic shock due to inverted takotsubo cardiomyopathy. He was treated with venoarterial extracorporeal membrane pulmonary oxygenation (ECMO) in combination with an intra-aortic balloon pump. After the restoration of cardiac function, a successful transition to curative retroperitoneal paraganglioma resection was performed. We conclude that ECMO is a valuable option for undiagnosed endocrine emergencies, helping to restore cardiac function and allowing sufficient time for further accurate diagnosis and specific treatment.

Reverse Takutsubo Cardiomyopathy in a Patient with Phlegmasia Cerulea Dolens

Reverse takotsubo cardiomyopathy (rTTC) is a rare variant of takotsubo cardiomyopathy (TTC) which is characterized by reversible left ventricular (LV) dysfunction. Emotional and physical stress have been implicated in triggering TTC especially in postmenopausal women. TTC and its variants are becoming more recognized due to the widespread adoption of early coronary angiography in the setting of acute coronary syndromes. A man in his late 50s presented to the emergency department with left lower extremity pain, swelling, and cyanosis. Clinical assessment was consistent with phlegmasia cerulea dolens, with deep venous thrombosis detected by venous duplex ultrasound. During his admission, he developed clinical and EKG findings suggestive of acute coronary syndrome. Emergent coronary angiography and ventriculography revealed basal and midventricular hypokinesis with hyperdynamic left ventricular apex, depressed LV dysfunction without coronary artery obstruction diagnostic of reverse takotsubo cardiomyopathy. Venous thromboembolism is a rare finding but has been associated with takotsubo cardiomyopathy and should be considered in the appropriate setting.

Takotsubo cardiomyopathy in patients suffering from acute non-traumatic subarachnoid hemorrhage—A single center follow-up study

Background

Takotsubo cardiomyopathy (TTC) is an important complication of subarachnoid hemorrhage (SAH), that may delay surgical or endovascular treatment and may influence patient outcome. This prospective follow-up study intended to collect data on the prevalence, severity, influencing factors and long-term outcome of TTC in patients suffering from non-traumatic SAH.

Methods

Consecutive patients admitted with the diagnosis of non-traumatic SAH were included. Intitial assessment consisted of cranial CT, Hunt-Hess, Fisher and WFNS scoring, 12-lead ECG, transthoracic echocardiography (TTE), transcranial duplex sonography and collecting laboratory parameters (CK, CK-MB, cardiac troponin T, NT-proBNP and urine metanephrine and normetanephrine). Diagnosis of TTC was based on modified Mayo criteria. TTC patients were dichotomized to mild and severe forms. Follow-up of TTE, Glasgow Outcome Scale assessment, Barthel’s and Karnofsky scoring occurred on days 30 and 180.

Results

One hundred thirty six patients were included. The incidence of TTC in the entire cohort was 28.7%; of them, 20.6% and 8.1% were mild and severe, respectively. TTC was more frequent in females (30/39; 77%) than in males (9/39; 23%) and was more severe. The occurrence of TTC was related to mFisher scores and WFNS scores. Although the severity of TTC was related to mFisher score, Hunt-Hess score, WFNS score and GCS, multivariate analysis showed the strongest relationship with mFisher scores. Ejection fraction differences between groups were present on day 30, but disappeared by day 180, whereas wall motion score index was still higher in the severe TTC group at day 180. By the end of the follow-up period (180 days), 70 (74.5%) patients survived in the non-TTC, 22 (81.5%) in the mild TTC and 3 (27%) in the severe TTC group (n = 11) (p = 0.002). At day 180, GOS, Barthel, and Karnofsky outcome scores were higher in patients in the control (non-TTC) and the mild TTC groups than in the severe TTC group.

Conclusions

Takotsubo cardiomyopathy is a frequent finding in patients with SAH, and severe TTC may be present in 8% of SAH cases. The severity of TTC may be an independent predictor of mortality and outcome at 6 months after disease onset. Therefore, a regular follow-up of ECG and TTE abnormalities is warranted in patients with subrachnoid hemorrhage for early detection of TTC.

Trial registration

The study was registered at the Clinical Trials Register under the registration number of NCT02659878 (date of registration: January 21, 2016).

The Pivotal Role of Echocardiography in the Diagnosis of Stress-Induced Cardiomyopathy Presenting with Atypical Pattern in Critically Ill Children. An Illustrative Case Report

BACKGROUND

Takotsubo cardiomyopathy (TCM) has some distinctive features like greater proportion of reverse-TCM and central nervous system disease as a prevalent triggering cause. We expose the case of a child with cardiogenic shock presenting an atypical echocardiographic TCM pattern on an echocardiography, after an acute neurologic trigger. We also include a systematic literature review of previously described cases of atypical-TCM in children.

CASE REPORT

A previously healthy 9 year-old boy with status epilepticus presented abrupt cardiogenic shock. The EKG showed signs of myocardial ischemia, cardiac biomarkers NT-proBNP (2756 pg/mL ) and Troponin I (1707 pg/mL ) , and the echocardiography exposed a dilated LV with severely reduced systolic function (LVEF 28%) along with hypokinetic mid-basal segments (circumferential ballooning), and preserved hypercontractile apical segments, with the normal origin of both coronary arterial systems. A presumptive diagnosis of "reverse", "inverse" or atypical Takotsubo cardiomyopathy was built based on the echocardiographic findings, apart from the ACS-like EKG findings, the raised cardiac biomarkers, and the neurological trigger of the hyper catecholaminergic state. Despite cardiovascular improvement with supportive treatment, the patient eventually expired on day 2 after PICU admission due to neurological complications. As shown in our systematic review, only 19 similar cases have been reported to date.

CONCLUSION

With the report of this unusual case, we aim to point out the fundamental role of bedside echocardiography as a diagnostic test for critically ill children presenting with ACS-like in the context of neurosurgical emergencies, where bedside echocardiography itself can accurately establish a presumptive diagnosis of TCM.

Reverse Takotsubo cardiomyopathy with left bundle branch block after anesthesia induction in a patient with subarachnoid hemorrhage: a case report

Takotsubo or reverse Takotsubo cardiomyopathy is a well-known cardiac complication of subarachnoid hemorrhage (SAH) that shows transient left ventricular wall motion abnormalities with electrocardiogram (ECG) changes. ST change followed by T inversion is a common ECG finding complicated with these disorders, left bundle branch block (LBBB) may be a potential ECG pattern which is seen. In this case, we describe the clinical profile and outcomes of a patient with LBBB and reverse Takotsubo cardiomyopathy after anesthetic induction, which was scheduled as an emergent external ventricular drainage after SAH. This is the first report of an LBBB pattern in reverse Takotsubo cardiomyopathy.

Reverse Takotsubo Cardiomyopathy in the Setting of Acute Asthma Exacerbation

Takotsubo cardiomyopathy (TTC) is a reversible form of myocardial injury characterized by transient systolic and diastolic dysfunction secondary to regional left ventricle (LV) wall motion abnormalities. We present a case of a rare variant of TTC, termed reverse TTC (rTTC), involving basal hypokinesis with apical hyperkinesis accounting for less than 5% of identified cases of TTC. Our patient is a 49-year-old Hispanic female who presented for evaluation of dyspnea. She was diagnosed with acute asthma exacerbation. The patient admitted to more frequent use of her albuterol rescue inhaler. Over the course of her hospitalization the patient had elevation of Troponin I and underwent an echocardiogram and coronary angiogram, which revealed the diagnosis of rTTC in the setting of inhaled beta agonist overuse for acute asthma exacerbation. Our case highlights the importance of adequately managing asthma to prevent exacerbation and overuse of inhaled sympathomimetic agents in an effort to decrease the incidence of TTC in the asthmatic population.

Cardiac Arrest and Inverted Takotsubo Cardiomyopathy Following Intramyometrial Vasopressin Injection During Myomectomy

Vasopressin is involved in cardiovascular homeostasis that can influence coronary perfusion. It is commonly used as a local vasoconstricting agent during gynaecological procedures. We present a case of cardiac arrest and inverse Takotsubo features following intramyometrial vasopressin administration during myomectomy. The patient was successfully resuscitated and recovered completely. Cardiac presentation was compatible with inverse Takotsubo cardiomyopathy that could have been triggered by high-dose vasopressin-induced coronary vasoconstriction. The patient's cardiac function resolved with no long-term sequelae. Takotsubo cardiomyopathy usually results from an excessive catecholaminergic surge. High-dose vasopressin-induced coronary vasospasm could have been the mechanism underlying the clinical presentation in our patient.

LEARNING POINTS

Local vasopressin administration during gynaecological procedures can result in rare but severe cardiovascular compromise.Takotsubo cardiomyopathy can result from multiple rare causes.High-dose vasopressin may cause Takotsubo cardiomyopathy features via coronary vasoconstriction.

Electrocardiographic changes in Takotsubo cardiomyopathy

Takotsubo Cardiomyopathy (TC) is a syndrome characterized by reversible left ventricular dysfunction in the presence of possible emotional or physical triggers but without evidence of obstructive coronary artery disease. It has become increasingly reported worldwide and is associated with significant morbidity and mortality. TC may present with an array of electrocardiographic (ECG) findings. These ECG findings, if accurately interpreted, can play an important role in the diagnosis and risk stratification of this syndrome. In the last three decades since the disease was first described, multiple diagnostic criteria have been established. The key diagnostic tools for TC include clinical symptomatology, cardiac biomarkers, non-invasive cardiac imaging, and coronary angiography. The ECG findings in TC can be variable, however, some ECG scores have been proposed in association with TC with reasonably good diagnostic sensitivity and specificity. This article aims to provide a succinct review of important electrocardiographic findings associated with TC and its impact on clinical outcomes.

Successful use of the impella ventricular assist device for management of reverse Takotsubo Cardiomyopathy in the setting of acute intracranial hemorrhage

Reverse Takotsubo Cardiomyopathy (rTTC) is a rare variant of Takotsubo Cardiomyopathy (TTC) that is characterized by hypokinesis of the base and sparing of the mid to apical wall of the left ventricle best seen on echocardiogram. Intracranial hemorrhage (ICH) has been identified as a risk factor rTTC. Nearly around 10% of the patients with TTC develop cardiogenic shock. We hereby report the successful use of the Impella Ventricular Assist Device (Impella CP®) for management of rTTC in the setting of acute ICH. Our patient is a young female who presented with loss of consciousness after an acute headache and imaging studies revealed left posterior cerebral artery aneurysm with intraventricular hemorrhage. Subsequently the patient developed hypoxia, severe hypotension and cardiac arrest. After resuscitation, an echocardiogram showed that the patient had rTTC and a cardiac angiogram showed patent coronary arteries. The Impella CP® was successfully inserted followed by immediate cerebral angiography and aneurysmal coiling. Systemic anticoagulation was started during coiling. In the next three days, the patient's left ventricular function recovered, and she was discharged home. Up to our knowledge, this is the first case report to mark the successful placement of the Impella CP® with delayed initial anticoagulation for management of rTTC. Our patient was challenging as there are no current guidelines in the management of cardiogenic shock secondary to rTTC in the setting of acute ICH.

Change of heart: Reverse takotsubo's cardiomyopathy - A case report

Reverse takotsubo's cardiomyopathy is a rare and relatively unknown variant of takotsubo's cardiomyopathy, also known as stress cardiomyopathy or broken heart syndrome. There are significant differences in the patient age and clinical profiles between classic and reverse takotsubo's cardiomyopathy. Classic takotsubo's cardiomyopathy has been extensively described. However, the little described literature related to reverse takotsubo's cardiomyopathy is limited to the cardiology speciality, with a relative paucity described in radiology. We describe a case report of a 73 year-old female who was diagnosed with reverse takotsubo's cardiomyopathy on the basis of Cardiac MRI. Herein, we hope to bring more awareness of this condition and describe its features on MRI.

Takotsubo syndrome in young fertile women

Background: Takotsubo syndrome (TTS) is an acute heart syndrome characterised by reversible ventricular dysfunction with the absence of significant coronary occlusion, which typically occurs in postmenopausal women after emotional or physical stress. Differences of clinical or instrumental characteristics between fertile women and postmenopausal women with TTS have not yet been studied. The aim of this study was to investigate the differences in clinical, biochemical and echocardiographic characteristics between postmenopausal women and fertile women with TTS.Methods: One hundred and thirty-one patients (mean age 67.8 ± 11.3 years; 14 patients were still fertile) from four different Italian hospitals were enrolled, partially retrospectively and partial longitudinally. Physical examination, clinical history (including presenting symptoms and triggering stress factors), laboratory and ECG findings and Doppler echocardiography were collected at hospital admission. Echocardiography was repeated at discharge (after at least seven days from admission).Results: No significant differences were observed considering trigger events or symptoms at presentation. Significant differences were observed considering left ventricle ejection fraction (LVEF) (37.9 ± 14.4% in fertile women, 43.9 ± 9.7% in postmenopausal women, p = .033) and regional wall motion abnormalities. The apical ballooning pattern was predominant in postmenopausal women, instead the midventricular type was mainly observed in fertile women (36% versus 1% in fertile versus postmenopausal women respectively, p < .001).Conclusions: Echocardiographic involvement of left ventricle is atypical in fertile women compared to women in menopause (midventricular versus apical ballooning, respectively). Moreover, the young group presented with worse LVEF but they had the same LV function at discharge and similar prognosis.

Takotsubo Cardiomyopathy presenting with different morphological patterns in the same patient: a case report and review of the literature

BACKGROUND

Takotsubo Cardiomyopathy is characterized by transient left ventricular systolic dysfunction, which often mimics a myocardial infarction and is usually triggered by emotional or physical stress. There are four variants of Takotsubo Cardiomyopathy, based on the affected left ventricular area.

CASE

We report a 75-year-old female with a past medical history of diabetes mellitus, hypertension, hyperlipidemia, and chronic kidney disease who presented with chest pain that had started after a stressful, emotional event. Her electrocardiogram showed no ischemic changes, troponin was mildly elevated, and cardiac catheterization revealed nonobstructive coronary artery disease. Echocardiogram showed a decreased ejection fraction and apical akinesia with basal hyperkinesia consistent with classical Takotsubo Cardiomyopathy.

DECISION-MAKING

The patient symptomatically improved on optimal heart failure therapy, and a follow-up echocardiogram showed improvement in her systolic function. Over a year later, the patient was readmitted with chest pain, which also began after an emotional event. ECG showed nonspecific ST-T wave changes, and troponin was mildly elevated. Echocardiogram demonstrated a reduced ejection fraction and inferior akinesia with apical hyperkinesia consistent with reverse Takotsubo Cardiomyopathy. A repeat cardiac catheterization exhibited mild nonobstructive coronary artery disease unchanged from her previous report. A follow-up echocardiogram showed full recovery of her systolic function.

CONCLUSION

Classical and reverse Takotsubo Cardiomyopathy due to different stressors have been reported in the literature individually, but up to our knowledge, both variants of Takotsubo Cardiomyopathy occurring in the same patient has not been reported previously.

Delayed onset Takotsubo syndrome following exercise ECG: a case report

Background

Takotsubo syndrome usually occurs immediately following a physical or emotional trigger. In some cases, a triggering stress may not be evident. A delayed manifestation of the syndrome may account for such cases.

Case summary

An asymptomatic 69-year-old woman presented for a routine cardiac check-up, which revealed normal electrocardiogram (ECG), echocardiography, and exercise ECG. She did not complain of any chest pain during or immediately after the tests. After about 24 h, she developed chest pain for which she was admitted with the provisional diagnosis of acute coronary syndrome. ECG showed dynamic T-wave changes with QTc prolongation. Cardiac biomarkers were mildly elevated. Characteristic reversible left ventricular dysfunction in absence of coronary stenosis ultimately led to the diagnosis of Takotsubo syndrome.

Discussion

Our case represents a delayed occurrence of Takotsubo syndrome triggered by a treadmill exercise stress test, which manifested about 24 h following the stressor. Such delayed manifestation may account for those cases of Takotsubo syndrome where no immediate triggering stressor is evident.

A Unique Case of Midvariant Reverse Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy, also known as stress cardiomyopathy, is known to have 4 variants: apical, midventricular, basal, and focal. Here, we report the 2nd case of reverse midvariant (midventricular) stress cardiomyopathy and the 1st case of reverse midvariant takotsubo cardiomyopathy with apical thrombus.

Possible association of influenza A infection and reverse takotsubo syndrome

We present a case of reverse takotsubo syndrome (rTS) in a 68-year-old woman who presented with acute chest pain and flu-like symptoms. She was found to have elevated troponin and abnormal ECG. Urgent coronary angiogram revealed non-obstructive mild coronary artery disease of the left anterior descending artery. Left ventriculography demonstrated hypokinesis of the left ventricular base with sparing of the mid-ventricle and apex. Nasal viral PCR was positive for Influenza A. The diagnosis was confirmed with repeat echocardiogram 2 weeks later revealing resolution of regional wall motion abnormalities. rTS is a type of TS, mimicking acute coronary syndrome. It is seen in younger patients and often occurs with intense emotional and physical stress. Though many triggers have been reported, rTS associated with influenza A has not been previously documented.

Stress Cardiomyopathy Diagnosis and Treatment: JACC State-of-the-Art Review

Stress cardiomyopathy is an acute reversible heart failure syndrome initially believed to represent a benign condition due to its self-limiting clinical course, but now recognized to be associated with a non-negligible rate of serious complications such as ventricular arrhythmias, systemic thromboembolism, and cardiogenic shock. Due to an increased awareness and recognition, the incidence of stress cardiomyopathy has been rising (15-30 cases per 100,000 per year), although the true incidence is unknown as the condition is likely underdiagnosed. Stress cardiomyopathy represents a form of neurocardiogenic myocardial stunning, and while the link between the brain and the heart is established, the exact pathophysiological mechanisms remain unclear. We herein review the proposed risk factors and triggers for the syndrome and discuss a practical approach to diagnosis and treatment of the patients with stress cardiomyopathy, highlighting potential challenges and unresolved questions.

Reverse Takotsubo Cardiomyopathy Following Exploratory Laparotomy

Reverse takotsubo cardiomyopathy is an uncommon cardiomyopathy characterized by reversible regional wall motion abnormalities in the basilar segment of the left ventricle. This happens in the absence of any coronary artery pathology. Although it shares some pathogenic mechanisms with its more common variant, takotsubo cardiomyopathy, differences exist in terms of echocardiographic features, demographics, clinical manifestations, laboratory features, and prognosis. Cases of postoperative reverse takotsubo cardiomyopathy are less described in the literature. Herein, we report a case of reverse takotsubo cardiomyopathy in a 44-year-old woman occurring after exploratory laparotomy.

Takotsubo Cardiomyopathy in the Emergency Department: A FOCUS Heart Breaker

Takotsubo cardiomyopathy (TCM) is an important condition for the emergency physician to consider in patients with cardiovascular symptoms. A 70-year-old woman presented with chest pain and nausea following emotional trauma. She had an elevated troponin and a normal electrocardiogram with no history of previous cardiac disease. Point-of-care focused cardiac ultrasound (FOCUS) showed reduced left ventricular systolic function with mid to apical hypokinesis. Cardiac catheterization revealed clean coronary arteries and confirmed the suspected diagnosis of TCM. Few reports emphasize the importance of FOCUS in the diagnosis and management of TCM in the emergency department. We detail FOCUS findings that assisted with diagnosis of TCM and describe how this quick, noninvasive imaging modality can be used to assess and manage emergent conditions.

Fast ‘wandering’ Takotsubo syndrome: atypical mixed evolution from apical to mid-ventricular ballooning

We report the case of a 53-year-old woman admitted for typical chest pain and a diagnosis of Takotsubo syndrome (TTS). Initial echocardiographic presentation was characterized by apical and mid-ventricular akinesis and basal hyper-kinesis. Unexpectedly, later after admission, echocardiography showed recovered apical akinesis with an apparent ‘migration’ of systolic dysfunction to mid-ventricular segment and hyper-kinesis of apical and basal segments. One week after admission, left ventricular contractility completely recovered and cardiac magnetic resonance imaging did not show signs of subendocardial late-enhancement and myocardial edema. Cases of TTS may therefore occasionally rapidly ‘wander’ within left ventricular segments, raising doubts over the so far used classification of left ventricular patterns of ballooning in subjects with TTS (typical/atypical). Apparently, different patterns can rapidly evolve into each other. The absence of late-enhancement at cardiac magnetic resonance imaging could hypothetically identify rapidly ‘wandering’ cases.

Takotsubo cardiomyopathy: Pathophysiology and role of cardiac biomarkers in differential diagnosis

Takotsubo cardiomyopathy (TC) is characterized by reversible ventricular dysfunction, not limited to the distribution of an epicardial coronary artery. A disease primarily afflicting post-menopausal women, it is frequently mistaken for acute anterior wall myocardial infarction. Alternatively called Stress Cardiomyopathy, physical or emotional triggers are identified in only three fourths of TC patients. Long considered a benign condition, recent findings suggest poor short term prognosis similar to acute coronary syndrome (ACS). Despite the widely recognized pathophysiological role of catecholamine excess, its diagnostic role is uncertain. TC is suspected based on typical wall motion abnormalities in ventriculogram or echocardiogram. Several additional electrocardiographic, laboratory and imaging parameters have been studied with the goal of clinical diagnosis of TC. While several clinical clues differentiate it from ACS, a clinical diagnosis is often elusive leading to avoidable cardiac catheterizations. Natriuretic peptides (NPs), a family of peptide hormones released primarily in response to myocardial stretch, play a significant role in pathophysiology, diagnosis as well as treatment of congestive heart failure. TC with its prominent ventricular dysfunction is associated with a significant elevation of NPs. NPs are elevated in ACS as well but the degree of elevation is typically lesser than in TC. Markers of myocardial injury such as troponin are usually elevated to a higher degree in ACS than in TC. This differential elevation of NPs and markers of myocardial injury may play a role in early clinical recognition of TC.

Update on the Role of Cardiac Magnetic Resonance in Acquired Nonischemic Cardiomyopathies

Cardiomyopathies refer to a variety of myocardial disorders without underlying coronary artery disease, valvular heart disease, hypertension, or congenital heart disease. Several imaging modalities are available, but cardiac magnetic resonance (CMR) has now established itself as a crucial imaging technique in the evaluation of several cardiomyopathies. It not only provides comprehensive information on structure and function, but also can perform tissue characterization, which helps in establishing the etiology of cardiomyopathy. CMR is also useful in establishing the diagnosis, providing guidance for endomyocardial biopsy, accurate quantification of function, volumes, and fibrosis, prognostic determination, risk stratification, and monitoring response to therapy. In this article, we review the current role of CMR in the evaluation of several acquired nonischemic cardiomyopathies, particularly focusing on recent advances in knowledge. We also discuss in detail a select group of common acquired nonischemic cardiomyopathies.

Why Is Reverse Takotsubo "Reverse"?

OBJECTIVES

Takotsubo cardiomyopathy (TTC) is an acute cardiac syndrome simulating myocardial infarction that is characterized by transient wall motion abnormalities in the absence of coronary artery obstruction. Reverse TTC (rTTC) is a recently described variant of TTC. This review defines and compares both forms of TTC, stating their resemblances and differences.

METHODS

We conducted a search of the MEDLINE database. Forty-one cases of rTTC met our eligibility criteria and were summarized in a synthesis of the demographic features, clinical characteristics, and laboratory studies.

RESULTS

Of the 41 patients studied, 73% were women. Patients' ages ranged from 19 to 69 years and the mean age was 43. The predominant electrocardiogram finding was ST-segment depression, whereas ST-segment elevation was present in only 6 patients (14.5%). Troponin levels were raised in 92.6% of the patients, with a mean troponin I of 7.7 ng/mL. All of the patients had wall motion abnormalities on echocardiography and the mean ejection fraction was 29.3%. Of the 27 patients (66%) who had a documented angiography, 22 (81.5%) had normal coronaries and 5 (18.5%) had minor or mild obstructive coronary artery disease. Of the 41 patients, 9 (22%) died, and the mean recovery time of the ejection fraction in the survivors was 16 days.

CONCLUSIONS

rTTC is a distinct presentation from the classic TTC. Remarkable differences exist between both forms in terms of mean age, sex, electrocardiogram presentation, troponin levels, and mortality.

Extracorporeal Membrane Oxygenation for Treatment of Acute Inverted Takotsubo-Like Cardiomyopathy From Hemorrhagic Pheochromocytoma in Late Pregnancy

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.

Cardiac Magnetic Resonance in Takotsubo Syndrome

Takotsubo syndrome is an acute, profound but reversible heart failure syndrome of unknown aetiology, usually but not always triggered by physical or emotional stress. Cardiac magnetic resonance has become an important tool for the non-invasive assessment of the syndrome, allowing for a comprehensive, safe and reproducible assessment of functional and anatomical myocardial properties, including perfusion, oedema and necrosis. This review focuses on the emerging role of cardiac magnetic resonance for the characterisation, differential diagnosis as well as risk stratification of patients with Takotsubo syndrome.

The ECG in the differential diagnosis between takotsubo cardiomyopathy and acute coronary syndrome

INTRODUCTION

Takotsubo cardiomyopathy (TC) is an acquired cardiomyopathy affecting mostly postmenopausal women mimicking an acute coronary syndrome (ACS). TC clinical presentation involves chest pain, elevated cardiac enzymes, wall motion abnormalities and electrocardiographic changes, all of which share striking similarities to ACS. Areas covered: Differential diagnosis between TC and ACS can be complex since there are no reliable and widely-accepted electrocardiographic criteria and, at the moment, only coronary angiography can rule out one of the two diagnoses with good certainty. The present review will discuss the pros and cons of the ECG in TC, focusing on how the signal changes through the acute phase, the hospitalization, and after discharge. Specific information will be provided for each component of the ECG trace, and potential pitfalls will be highlighted, in order get to the core of this important unmet clinical issue. Expert commentary: There are at least several reasons why the ECG is still not considered a useful tool in differential diagnosis between TC and ACS. These include recent awareness of the syndrome, lack of evidence-based therapy, and, more importantly, a wide range of ECG features according to race, patient characteristics, wall motion abnormalities, triggers, and time from symptoms onset.

Cardiogenic Shock due to Psychosis-Induced Inverted Takotsubo Cardiomyopathy Bridged-to-Recovery with a Percutaneous Left Ventricular Assist Device

Inverted Takotsubo cardiomyopathy, a less common variant in the spectrum of stress-induced cardiomyopathy, is increasingly being reported. This report describes an acute psychiatric illness leading to the onset of this syndrome. The patient presented here developed cardiogenic shock but successfully recovered with the use of a percutaneous left ventricular assist device.

Prognostic Usefulness of the Ballooning Pattern in Patients With Takotsubo Cardiomyopathy

The aim of the present analysis was to evaluate the prognostic impact of different ballooning patterns in patients with Takotsubo cardiomyopathy (TTC). A total of 285 consecutive patients with TTC were included. Clinical characteristics and short- and long-term outcomes were compared between patients with typical apical ballooning (n = 204) and patients with an atypical ballooning pattern including midventricular and basal ballooning (n = 81). Patients with typical apical ballooning were significantly older (73.3 ± 10.2 vs 68.4 ± 10.3 years; p <0.01) and had a higher prevalence of diabetes mellitus (25.5% vs 12.3%; p = 0.02). The initial left ventricular (LV) ejection fraction was significantly lower in case of apical ballooning (41.5 ± 10.4% vs 46.9 ± 10.9%; p <0.01) but recovered to normal values in both groups (58.4 ± 8.0 vs 59.7 ± 7.0; p = 0.25). Although 28-day mortality did not differ significantly (p = 0.10), typical apical ballooning was associated with an increased 6-month (13.4% vs 1.3%; hazard ratio [HR] 10.81, 95% confidence interval [CI] 1.47 to 79.66; p = 0.02) and long-term mortality rates (28.9% vs 14.5%; HR 2.24, 95% CI 1.17 to 4.71; p = 0.02). A landmark analysis which included only patients who survived the first 6 months after the initial event demonstrated similar mortality rates in patients with typical (17.9%) and atypical (13.3%) ballooning (HR 1.36, 95% CI 0.67 to 2.79; p = 0.40). In conclusion, in patients with TTC, typical apical ballooning is associated with more severe LV dysfunction at acute presentation and higher mortality rates within the first 6 months after the initial event. After complete recovery of LV function, prognosis is similar in patients with typical and atypical ballooning patterns.

Acute left ventricle failure on induction of anesthesia: a case report of reverse stress cardiomyopathy-presentation, diagnosis and treatment

Reverse takotsubo cardiomyopathy (TCM) is a less common variant of classic TCM that presents within a different patient profile and with its own hemodynamic considerations. A 46-year-old woman was admitted to our hospital for laryngoscopy and possible balloon dilatation for tracheal stenosis under general anesthesia. One year prior to this admission, the patient was admitted after a motor vehicle accident with subdural hematoma, subarachnoid hemorrhage, and fracture of the eighth thoracic vertebra. She underwent uneventful anesthesia for thoracic spine surgery and tracheostomy to help her wean from the ventilator during that admission. Since her previous admission, she developed posttraumatic anxiety and depression (a neuropsychiatric disorder triggered by subdural hematoma and subarachnoid hemorrhage) and was treated with antianxiety and antidepressant medication. At this admission, the patient developed acute left ventricle failure on induction of anesthesia secondary to reverse TCM. We report a case of reverse TCM, where posttraumatic emotional stress of a neuropsychiatric disorder combined with physical stress from anesthesia and laryngoscopy triggered TCM in a patient with previous uneventful anesthesia 1 year earlier.

Therapy of stress (takotsubo) cardiomyopathy: present shortcomings and future perspectives

Several therapeutic options are available for the treatment of the acute phase of stress cardiomyopathy, pharmacological (β-blockers, diuretics, anticoagulants, antiarrhythmics, noncatecholamine inotropics [levosimendan]), and nonpharmacological (intra-aortic balloon pumping, extracorporeal membrane oxygenation), according to the wide possible clinical presentation and course of the disease. However, there is a gap in evidence, and very few data come from randomized and adequately powered studies. Some evidence supports the use of β-blockers, in particular with a short half-life, in the case of left ventricular outflow tract obstruction, and angiotensin-converting enzyme inhibitors in secondary prevention. Future perspectives include the study of genetic basis of stress cardiomyopathy, role of miRNA and neurovegetative modulation. Randomized studies, however, are surely warranted.

Takotsubo syndrome: Advances in the understanding and management of an enigmatic stress cardiomyopathy

Takotsubo cardiomyopathy is a syndrome mimicking an acute myocardial infarction in absence of obstructive epicardial coronary artery disease to explain the degree of the wall motion abnormalities. Typically more common in the elderly women, this condition is usually triggered by unexpected emotional or physical stress situations, and is associated with electrocardiogram abnormalities and slight elevation of cardiac biomarkers. The pathophysiological mechanism is not clear yet, but it is believed that a high circulating concentration of catecholamines causes an acute dysfunction of the coronary microcirculation and metabolism of cardiomyocytes, leading to a transient myocardial stunning. Typically, it presents with acute left ventricular systolic dysfunction that in most cases is completely resolved at short term. Recurrences are rare and it is thought that the long-term prognosis is good. We present here a review of the clinical features, pathophysiology and management of this enigmatic condition.

Clinical and Echocardiographic Characteristics of Acute Cardiac Dysfunction Associated With Acute Brain Hemorrhage - Difference From Takotsubo Cardiomyopathy

BACKGROUND

Cardiac dysfunction (CD) associated with brain hemorrhage is similar to that with takotsubo cardiomyopathy but still not well understood. We aimed to investigate the clinical and echocardiographic findings of acute CD (ACD) related to brain hemorrhage.

METHODS AND RESULTS

Between 2013 and 2014, consecutive patients diagnosed with spontaneous and traumatic brain hemorrhage were prospectively enrolled. Electrocardiography, cardiac enzymes, and echocardiography were performed. Left ventricular (LV) systolic dysfunction on echocardiography was defined as ACD related to brain hemorrhage when all the following conditions were satisfied: abnormal ECG and cardiac troponin level, LV wall motion abnormality or decreased LV systolic function on echocardiography, and no previous history of cardiac disease. Otherwise, LV dysfunction was considered to be other CD unrelated to brain hemorrhage. In a total of 208 patients, 15 (7.2%) showed ACD. Of them, 8 patients were men and 8 showed apex-sparing LV hypokinesia and 9 died in hospital. Other cardiac abnormalities observed in the study patients were NT-proBNP elevation (n=123), QT interval prolongation (n=95), LV hypertrophy (n=89), and troponin I elevation (n=47). There were 36 in-hospital deaths (17.3%). Glasgow coma score and ACD were independently associated with in-hospital death.

CONCLUSIONS

ACD was observed in patients with various brain hemorrhages. Unlike takotsubo cardiomyopathy, high proportions of male sex, apex-sparing LV dysfunction, and in-hospital death were observed for ACD associated with brain hemorrhage. (Circ J 2016; 80: 2026-2032).