Recurrent Takotsubo Cardiomyopathy in a Patient With Hypertrophic Cardiomyopathy Leading to Cardiogenic Shock Requiring VA-ECMO

A Rare Case of Recurrent Takotsubo Cardiomyopathy Complicated by Thromboemboli

Takotsubo syndrome (TTS) is a transient ventricular dysfunction with apical ballooning triggered by emotional and/or physical stress. A few risk factors have been observed in patients with recurrent TTS, for example, excessive sympathetic stimuli, medications, stress, and tumors. Clinical features can vary from chest pain to overt hemodynamic instability. Diagnosis requires both electrocardiographic features and invasive imaging such as angiography to rule out other causes of cardiomyopathy prior to diagnosis. In addition, renal infarcts presenting as a complication of TTS are relatively uncommon. In this case report, we discuss the case of a 61-year-old African American woman with a prior history of TTS being managed for abdominal pain who developed a recurrence of the TTS during the hospital course. Prompt diagnosis and management of the condition is crucial to improve outcomes especially in patients with thromboembolic phenomenon or hemodynamic instability. Further large-scale studies are warranted to determine outcomes of patients with recurrent Takotsubo cardiomyopathy with thromboembolic phenomenon.

Intra-Aortic Balloon Pump Exacerbates Left Ventricular Outflow Tract Obstruction in a Patient With Takotsubo and Hypertrophic Cardiomyopathy

•Obstructive HCM with superimposed takotsubo syndrome led to shock. •The use of an IABP worsened outflow obstruction. •Putting the IABP on standby improved outflow tract gradients dramatically. •An IABP should not be used in shock with LVOT obstruction.

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

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

The predictive value of deep learning-based cardiac ultrasound flow imaging for hypertrophic cardiomyopathy complicating arrhythmias

OBJECTIVE

To investigate the predictive value of deep learning-based cardiac ultrasound flow imaging for hypertrophic cardiomyopathy (HCM) complicated by arrhythmias.

METHODS

The clinical data of 158 patients with hypertrophic cardiomyopathy were retrospectively collected from July 2019 to December 2021, and additionally divided into training group 106 cases, validation group 26 cases and test group 26 cases according to the ratio of 4:1:1, and divided into concurrent and non-concurrent groups according to whether they were complicated by arrhythmia or not, respectively. General data of patients (age, gender, BMI, systolic blood pressure, diastolic blood pressure, HR) were collected, a deep learning model for cardiac ultrasound flow imaging was established, and image data, LVEF, LAVI, E/e', vortex area change rate, circulation intensity change rate, mean blood flow velocity, and mean EL value were extracted.

RESULTS

The differences in general data (age, gender, BMI, systolic blood pressure, diastolic blood pressure, HR) between the three groups were not statistically significant, P > 0.05. The differences in age, gender, BMI, systolic blood pressure, diastolic blood pressure, HR between the patients in the concurrent and non-concurrent groups in the training group were not statistically significant, P > 0.05.

CONCLUSIONS

Deep learning-based cardiac ultrasound flow imaging can identify cardiac ultrasound images more accurately and has a high predictive value for arrhythmias complicating hypertrophic cardiomyopathy, and vortex area change rate, circulation intensity change rate, mean flow velocity, mean EL, LAVI, and E/e' are all risk factors for arrhythmias complicating hypertrophic cardiomyopathy.

Review of Contemporary Invasive Treatment Approaches and Critical Appraisal of Guidelines on Hypertrophic Obstructive Cardiomyopathy: State-of-the-Art Review

BACKGROUND

Hypertrophic obstructive cardiomyopathy (HOCM) is a heterogeneous disease with different clinical presentations, albeit producing similar dismal long-term outcomes if left untreated. Several approaches are available for the treatment of HOCM; e.g., alcohol septal ablation (ASA) and surgical myectomy (SM). The objectives of the current review were to (1) discuss the place of the standard invasive treatment modalities (ASA and SM) for HOCM; (2) summarize and compare novel techniques for the management of HOCM; (3) analyze current guidelines addressing HOCM management; and (4) offer suggestions for the treatment of complex HOCM presentations.

METHODS

We searched the literature and attempted to gather the most relevant and impactful available evidence on ASA, SM, and other invasive means of treatment of HOCM. The literature search yielded thousands of results, and 103 significant publications were ultimately included.

RESULTS

We critically analyzed available guidelines and provided context in the setting of patient selection for standard and novel treatment modalities. This review offers the most comprehensive analysis to-date of available invasive treatments for HOCM. These include the standard treatments, SM and ASA, as well as novel treatments such as dual-chamber pacing and radiofrequency catheter ablation. We also account for complex pathoanatomic presentations and current guidelines to offer suggestions for tailored care of patients with HOCM. Finally, we consider promising future therapies for HOCM.

CONCLUSIONS

HOCM is a heterogeneous disease associated with poor outcomes if left untreated. Several strategies for treatment of HOCM are available but patient selection for the procedure is crucial.

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

Background

Cardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction.

Methods and Results

We analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β‐blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra‐aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function.

Conclusions

When cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function.