Mechanisms of Acute Mitral Regurgitation in Patients With Takotsubo Cardiomyopathy

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.

Tricuspid annular disjunction with varying degrees of tricuspid regurgitation in the setting of Takotsubo syndrome

Tricuspid annular disjunction (TAD) is concomitant in approximately half of mitral annular disjunction (MAD) cases. Here we report a case of echocardiographically isolated TAD detected during Takotsubo syndrome (TTS) complicated by a transient aggravation of tricuspid regurgitation. An 87-year-old female was admitted at the emergency department with ST segment elevation. Coronary angiography findings were consistent with TTS. Transthoracic echocardiography (TTE) showed a left ventricular apical aneurysm with incidental finding of TAD with 'torrential' tricuspid regurgitation. Importantly, no concomitant MAD was detected on TTE. No significant arrhythmias were detected on telemetry surveillance. Follow up TTE showed improvement in left ventricular function with reduced regional wall abnormalities. TAD was still present although the tricuspid regurgitation had reduced to 'moderate'. The patient was discharged home after 23 days of hospital stay. The present case illustrates the need of further investigations into TAD and its clinical implications for acute TR in TTS.

Takotsubo cardiomyopathy in India and its electrocardiography (ECG) comparison to myocardial infarction

BACKGROUND

Owing to the limited research on Takotsubo Cardiomyopathy (TCM) in Asia, we aim to evaluate in detail the clinical profiles, lab parameters, investigations, and major adverse cardiovascular events (MACE) seen in patients with TCM in the Indian subcontinent. Additionally, we have compared the electrocardiographic findings of patients with TCM to those of patients with myocardial infarction (MI).

RESULTS

The average age of the patients affected was found to be 60 ± 11 years. Women (87.5%) and patients with hypertension (40%) were found to be at an increased risk of developing the syndrome. The most common presenting symptom was dyspnea (48%) following a trigger most commonly emotional (45%). ST elevation and significant T wave inversions were observed in 40% of patients with TCM. Echocardiography revealed a low left ventricular ejection fraction of 43 ± 9%. Coronary angiography was normal in 60%, the rest had mild/subcritical stenoses. The 6-month MACE was 20% and the mortality rate was 7.5%. Follow-up echocardiography of patients with TCM showed improvement in EF in 75% patients.

CONCLUSIONS

TCM was majorly seen in postmenopausal women following an emotional trigger, but a variety of other triggers were noted. T-wave inversions in TCM follow a diffuse pattern in contrast to specific leads seen in MI. Normal or subcritical stenosis in coronaries at presentation, along with a low EF which improves on follow up provide greater evidence for the diagnosis of TCM.

Gender Differences in Takotsubo Syndrome

Simple Summary

The manifestation of Takotsubo Syndrome (TTS) may be different in males and females based on past reports and our clinical research. However, the gender differences in TTS are unknown because patients with TTS are predominantly female. TTS is common in females; however, approximately 10–20% of males have TTS and it has been reported that in-hospital complications mostly occur in males. TTS in males is often caused by physical stress and often develops in the hospital or during hospitalization. TTS in males is associated with severe cardiac complications, which may require careful observations and interventions. Regarding the pathogenic mechanism of TTS, it has been reported that decreased estrogen levels, common in postmenopausal females, are involved in the pathogenic mechanism. Moreover, the pathological findings and gene expression were different in males and females. From these results, it can be considered that the mechanism of the onset of TTS may be different between males and females.

Abstract

Most patients with Takotsubo Syndrome (TTS) are postmenopausal females. TTS in males is rare and gender differences have not been sufficiently investigated. Therefore, we investigated gender differences in TTS. TTS in males and females is often triggered by physical and emotional stress, respectively. Heart failure, a severe in-hospital complication, requires greater mechanical respiratory support in males. Fatal arrhythmias such as ventricular tachycardia and ventricular fibrillation and in-hospital mortality rates are higher in males. The white blood cell (WBC) count has been shown to be higher in males than in females with cardiovascular death compared with non-cardiovascular death. Therefore, the WBC count, a simple marker, may reflect severe TTS. Decreased estrogen levels, common in postmenopausal females, are a pathogenic mechanism of TTS. Females have a more significant increase in the extracellular matrix-receptor interaction than males. Moreover, the pathological findings after hematoxylin–eosin staining were different in males and females. Males had more severe complications than females in the acute phase of TTS; thus, more careful observations and interventions are likely required. From these results, it can be considered that the mechanism of the onset of TTS may be different between males and females. Therefore, it is necessary to fully understand the gender differences in order to more effectively manage TTS.

Cardiovascular Imaging in Stress Cardiomyopathy (Takotsubo Syndrome)

Stress cardiomyopathy (Takotsubo syndrome) is a reversible syndrome stemming from myocardial injury leading to systolic dysfunction and is usually noted in the setting of a stressful event, be it an emotional or physical trigger. While the exact pathophysiology behind stress cardiomyopathy is yet unknown, there is ample evidence suggesting that neurocardiogenic mechanisms may play an important role. Although historically stress cardiomyopathy was generally thought to be a relatively benign condition, there is growing recognition of the cardiovascular complications associated with it despite its reversibility. Our review aims to shed light onto key cardiovascular imaging modalities used to diagnose stress cardiomyopathy while highlighting the role that imaging plays in assessing disease severity, identifying complications, dictating treatment approaches, and in short-term and long-term prognosis.

Stepwise approach for diagnosis and management of Takotsubo syndrome with cardiac imaging tools

Takotsubo syndrome is featured by transient left ventricle dysfunction in the absence of significant coronary artery disease, mainly triggered by emotional or physical stress. Its clinical presentation is similar to acute coronary syndrome; therefore, cardiac imaging tools have a crucial role. Coronary angiography is mandatory for exclusion of pathological stenosis. On the other side, transthoracic echocardiography is the first non-invasive imaging modality for an early evaluation of left ventricle systolic and diastolic function. Left ventricle morphologic patterns could be identified according to the localization of wall motion abnormalities. Moreover, an early identification of potential mechanical and electrical complications such as left ventricle outflow tract obstruction, mitral regurgitation, thrombus formation, right ventricular involvement, cardiac rupture, and cardiac rhythm disorders could provide additional information for clinical management and therapy. Because of the dynamic evolution of the syndrome, comprehensive serial echocardiographic examinations should be systematically performed. Advanced techniques, including speckle-tracking echocardiography, cardiac magnetic resonance, and nuclear imaging can provide mechanistic and pathophysiologic insights into this syndrome. This review focuses on these aspects and provide a stepwise approach of all cardiac imaging tools for the diagnosis and the management of Takotsubo syndrome.

Review of multi-modality imaging update and diagnostic work up of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is an acute but reversible non-ischemic heart failure syndrome. It is characterized by a transient form of ventricular dysfunction typically manifesting as basal hyperkinesis with hypokinesia and ballooning of left ventricle mid-cavity and apex. Imaging helps in both diagnosis and follow up. Echocardiogram is the first-line modality to assess the typical contractile dysfunction in suspected patients with catheter angiography showing normal coronary arteries. Cardiac MRI is currently the modality of choice for the non-invasive initial assessment of TC and for follow up imaging. The current review focusses on historical background of TC, its pathophysiology, diagnostic work up and differential diagnosis and provides multimodality imaging work up of TC including role of echocardiogram, invasive catheterization, nuclear imaging, cardiac computed tomography and cardiac MRI including basic and advanced MRI sequences.

Novel Imaging and Genetic Risk Markers in Takotsubo Syndrome

Takotsubo syndrome (TTS) is an increasingly recognized condition burdened by significant acute and long-term adverse events. The availability of novel techniques expanded the knowledge on TTS and allowed a more accurate risk-stratification, potentially guiding clinical management. The present review aims to summarize the recent advances in TTS prognostic evaluation with a specific focus on novel imaging and genetic markers. Parametric deformation analysis by speckle-tracking echocardiography, as well as tissue characterization by cardiac magnetic resonance imaging T1 and T2 mapping techniques, currently appear the most clinically valuable applications. Notwithstanding, computed tomography and nuclear imaging studies provided limited but promising data. A genetic predisposition to TTS has been hypothesized, though available evidence is still not sufficient. Although a genetic predisposition appears likely, further studies are needed to fully characterize the genetic background of TTS, in order to identify genetic markers that could assist in predicting disease recurrences and help in familial screening.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Advanced cardiac magnetic resonance imaging in takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is a reversible condition in which there is transient left ventricular (LV) dysfunction characterised most commonly by basal hyperkinesis and mid-apical LV ballooning and hypokinesia. It is said to be triggered by stress and mimics, such as acute coronary syndrome (ACS) clinically. Diagnosis is usually suspected on echocardiography due to the characteristic contraction pattern in a patient with symptoms and signs of ACS but normal coronary arteries on catheter angiography. Cardiac magnetic resonance (CMR), with its latest advancements, is the diagnostic modality of choice for diagnosis, prognosis and follow-up of patients. The advances in CMR (including T1, T2, ECV mapping and threshold-based late gadolinium enhancement (LGE) measurements have revolutionised the role of CMR in tissue characterisation and prognostication in patients with TC. In this review, we highlight the current role of CMR in management of TC and enumerate the CMR findings in TC as well the current advances in the field of CMR, which could help in prognosticating these patients.

Acute Mitral Regurgitation and Transcatheter Mitral Valve Repair in an Emergency Case: Focus on the Mechanical Disorder of Mitral Valve Complex

Acute mitral regurgitation is an uncommon, challenging disease that requires emergent care and proper management. To evaluate its etiology, echocardiography is essential. However, echocardiography findings in these patients are often different from that of chronic mitral regurgitation owing to the acute elevation of left atrial and pulmonary artery pressure derived from the small left ventricle and atrium with low compliance. Although surgical correction is usually required owing to the hemodynamic instability, many patients are considered to be at high surgical risk. Transcatheter mitral valve repair using MitraClip (Abbott Vascular, Santa Clara, CA) may be a solution as a bail-out therapy.

Impella in Takotsubo syndrome complicated by left ventricular outflow tract obstruction and severe mitral regurgitation

The treatment of cardiogenic shock in patients with Takotsubo syndrome (TTS) is challenging because it depends on the mechanisms leading to the haemodynamic instability.

We report the case of a 70‐year‐old woman admitted for TTS complicated by cardiogenic shock. The early echocardiographic identification of left ventricular outflow tract obstruction (LVOTO) and severe mitral regurgitation (MR) prompted us to implant an Impella CP assist device as a bridge‐to‐recovery therapy. After device positioning, the haemodynamic status improved and LVOTO and severe MR disappeared. Because of the persistence of severe hypotension, the mechanical circulatory support was continued in intensive care unit and stopped only 5 days later, when intraventricular gradient spontaneously dropped. The patient was discharged after 1 week in stable conditions.

Our case suggests that Impella circulating support may be a useful bridge‐to‐recovery therapeutic option in selected patients with cardiogenic shock due to TTS complicated by LVOTO and severe MR.

Takotsubo syndrome in elderly woman: The diagnosis by transthoracic echocardiography

Takotsubo syndrome has increasingly been recognized in the differential diagnosis of patients presenting with acute chest pain. Those affected are typically older women suffering after an emotional or physical stress. Normally it is a transient condition but complications including death have been reported. We reported a case of takotsubo syndrome who was initially diagnosed as acute coronary syndrome. The patient presented with typical angina, ST-T segment changes, and elevated high sensitive–troponin I. Coronary angiography showed normal coronary arteries. Transthoracic echocardiography revealed mild left atrial dilatation and left ventricle concentric hypertrophy, reduced left ventricle ejection fraction with circumferential hypokinetic, apical ballooning, systolic anterior motion, left ventricle outflow tract obstruction, and sigmoid septum hypertrophy. One month later, patient recovered and transthoracic echocardiography revealed improved heart anatomy and function. To differentiate takotsubo syndrome with other conditions, especially acute coronary syndrome, is crucial. Their clinical presentations are similar but the managements are different. The transthoracic echocardiography holds an important role in supporting the diagnosis of takotsubo syndrome.

Intraventricular thrombus and severe mitral regurgitation in the acute phase of takotsubo cardiomyopathy: two case reports

Background

Takotsubo cardiomyopathy is characterized by chest symptoms, electrocardiographic changes, and new regional wall motion abnormality in the apical segment of the left ventricle in the absence of obstructive coronary artery disease. Particularly, apical ballooning is broadly recognized as the classic form of takotsubo cardiomyopathy. Although the prognosis of most patients with takotsubo cardiomyopathy is generally favorable, complications associated with the morphological features of transient apical ballooning are not uncommon.

Case presentation

We describe two cases of transient complications in postmenopausal patients with takotsubo cardiomyopathy. Intraventricular thrombus was observed in Asian patient 1, and severe mitral regurgitation was observed in Asian patient 2. These complications were confirmed by transthoracic echocardiography immediately after typical takotsubo cardiomyopathy with apical ballooning was diagnosed. Anticoagulant therapy with heparin and warfarin was continued for 1 week in patient 1. After the therapy, complete resolution of the apical thrombus and recovery of systolic function of the left ventricle was observed by follow-up transthoracic echocardiography. In patient 2, transthoracic echocardiography indicated significant mitral regurgitation, which was caused by left ventricular tethering of the anterior mitral leaflet rather than left ventricular outflow tract obstruction or systolic anterior motion. Because the hemodynamic stability in patient 2 had been preserved, she was managed with conservative treatment. After approximately 1 month, follow-up transthoracic echocardiography revealed that mitral regurgitation had almost disappeared with complete resolution of left ventricular wall motion abnormalities.

Conclusions

The presented cases indicated that important complications, such as intraventricular thrombus and severe mitral regurgitation, are associated with takotsubo cardiomyopathy in the acute phase. Because these complications are risk factors for developing a thromboembolic event or heart failure and/or pulmonary edema, timely and accurate identification of these complications is critical to achieving optimal clinical outcomes in patients with takotsubo cardiomyopathy.

Acute mitral regurgitation

The diagnosis of acute mitral regurgitation (MR) is often missed or delayed because the clinical presentation is substantially different from that in patients with chronic MR. Management of acute MR depends on the specific aetiology of valve dysfunction and there is a lack of consensus on the optimal therapeutic approach in many patients. In particular, management of secondary MR due to acute ischaemia is challenging because of unique mechanisms of valve incompetence compared with chronic ischaemic MR. Another clinical challenge is management of acute MR due to transient systolic anterior motion of the mitral valve in the acute phase of Takotsubo cardiomyopathy, which commonly resolves within a few weeks. Additionally, iatrogenic MR induced by intraventricular devices is a recently recognised aetiology of acute MR. Acute primary MR typically requires early surgical intervention, for example, with a flail leaflet or endocarditis, because of acute cardiovascular decompensation with an abrupt increase in left atrial pressure. In an emergency situation and high surgical risk, a percutaneous mitral valve edge-to-edge repair is an alternative therapeutic option. Firm diagnosis of the severity and aetiology of acute MR is necessary for proper decision making, including timing and types of surgical intervention.

Mechanical interventricular dependency supports hemodynamics in tako-tsubo cardiomyopathy

Background

Although morphological abnormalities of the heart appear to be remarkable, most patients with tako-tsubo cardiomyopathy (TTC) remain clinically stable. We investigate real time changes in the left ventricular (LV) and right ventricular (RV) mechanics and function to explore the mechanism to preserve hemodynamics.

Methods

With deformation and Doppler echocardiography, we evaluated myocardial mechanics and ventricular function/hemodynamics simultaneously in 103 consecutive TTC patients admitted from 01/01/2008 through 12/31/2015. The coronary angiography and left ventriculography were performed to rule out culprit coronary artery stenosis (CAS). We included 66 patients in a control group with matched age, sex, and risk factors for coronary artery disease (CAD), and 41 patients in a group of myocardial infarction induced cardiogenic shock, who required circulatory supporting devices to maintain hemodynamic stability.

Results

Although systolic myocardial strain in most of the LV segments was significantly impaired, 4 basal LV segments remained functionally active during acute stage of TTC. The impairment in the myocardial strain of the RV apex could extend to the middle segments, but basal RV systolic strain was also preserved. Despites comparable apical to basal strain gradients, LV and RV displayed discrepant functional/hemodynamic status. In contrast to LV, RV functional/hemodynamic parameters appeared to be hyper-dynamic. This unique RV strain pattern remained unchanged in patients with atypical (mid-LV cavity) TTC. In 41 patients with myocardial infarction induced cardiogenic shock, RV exhibited comparable mechanic and functional features with those in TTC patients.

Conclusions

The identified LV and RV mechanic changes appear to support interventricular hemodynamic dependence during TTC, which may represent a universal rescue mechanism in a jeopardized or injured heart.

Tight coronary artery stenosis and takotsubo syndrome triggered each other: Well-illustrated in a case

Post-ischemic myocardial stunning (PIMS) is defined as a prolonged and reversible left ventricular dysfunction induced by an acute coronary ischemic insult. Takotsubo syndrome (TS) is a recognized acute cardiac disease entity, characterized by a unique pattern of transient circumferential left ventricular wall motion abnormality (LVWMA). The LVWMA in TS has all the characteristic features of myocardial stunning. Herein, the case of a 76-year-old woman with severe three-vessel coronary artery disease presented with acute coronary syndrome inducing PIMS with features identical to mid-apical pattern of TS is reported. The stunned myocardium caused incessant (throughout systole and diastole) compression of a segment of left anterior descending artery (LAD) with myocardial bridging during the acute and sub-acute stages of the disease. The systo-diastolic compression of LAD was relieved after recovery of LVWMA 26 days later. This novel observation suggests that the myocardial stunning in TS is in a cramp state during the acute and sub-acute stages of the disease. The cramp state of myocardial stunning may also explain the microvascular dysfunction seen in some patients with TS.

Role of echocardiography for takotsubo cardiomyopathy: clinical and prognostic implications

Takotsubo cardiomyopathy (TTC) is newly-described secondary cardiomyopathy characterized by transient left ventricular (LV) dysfunction, which is increasingly recognized in the field of cardiology. TTC occurs in approximately 2% of the patients with acute coronary syndrome. Its onset is rare; however, its specific features play a crucial role in diagnosing the chest pain in clinical practice. TTC has generally favorable outcome with rapid recovery of LV function; however, an increasing evidence suggests that it should be regarded as a more serious acute cardiac disorder with a variety of complications. Owing to its widespread availability, even in emergency settings, transthoracic echocardiography plays a key role in the diagnostic assessment of TTC and contributes to an increased number of disease detection and incidence reports in contemporary clinical practice. This review focuses on the role of echocardiography in understanding the clinical prognostic implications in patients with TTC.

Tako-tsubo Syndrome in Men: Rare, but With Poor Prognosis

INTRODUCTION AND OBJECTIVES

Tako-tsubo syndrome is a potentially serious disease during the acute phase. It mimics myocardial infarction, but with no potentially causative coronary lesions. The aim of this study was to analyze the clinical course and outcome of patients with tako-tsubo syndrome by sex.

METHODS

We analyzed the characteristics of patients included in the RETAKO registry from 2003 to 2015, a multicenter registry with participation of 32 Spanish hospitals.

RESULTS

Of 562 patients included, 493 (87.7%) were women. Chest pain was less frequent as an initial symptom in men than in women (43 [66.2%] vs 390 [82.8%]; P < .01). The prognosis was worse in men, with higher in-hospital mortality (3 [4.4%] vs 1 [0.2%]; P < .01), longer intensive care stay (4.2 ± 3.7 vs 3.2 ± 3.2 days; P = .03) and a higher frequency of severe heart failure (22 [33.3%] vs 95 [20.3%]; P = .02). However, dynamic obstruction at the left-ventricular outflow tract occurred exclusively in women (39 [7.9%] vs 0 [0.0%]; P = .02). The incidence of functional mitral regurgitation was also higher in women (52 [10.6%] vs 2 [2.9%]; P = .04).

CONCLUSIONS

Tako-tsubo syndrome shows wide differences by sex in terms of its incidence, presentation, and outcomes. Prognosis is worse in men.

Takotsubo syndrome

Takotsubo syndrome is a reversible acute heart failure frequently precipitated by an emotional or physical stress. The clinical presentation resembles acute coronary syndrome. Pathogenesis is complex and may involve brain-heart axis and neuro-hormonal stunning of the myocardium. Coronary angiography reveals normal epicardial arteries with no obstruction or spasm. NT-ProBNP maybe remarkably elevated. Regional wall motion akinesia (RWMA) of left ventricle extends beyond the territory of one coronary artery. Reduced left ventricle ejection fraction (LVEF) and RWMA recover in 6-12 weeks. Prognosis is generally good. Recent meta-analysis shows in-hospital mortality of 1-4.5% and recurrence rate of 5-10% during five year follow-up.

Contemporary Imaging in Takotsubo Syndrome

Transthoracic echocardiography is the first-line imaging modality for evaluating patients with Takotsubo syndrome (TTS). Beyond diagnosis, TTE enables detection of peculiar complications and is useful for risk stratification and management of patients with cardiogenic shock. Cardiac magnetic resonance can be used to detect myocardial edema typically associated with TTS and is helpful in the differential diagnosis with other disease states. Coronary computed tomography angiography can be performed as an alternative to coronary angiography to confirm coronary artery patency. Molecular imaging is a promising approach for identifying patients at increased risk of recurrence.

Contemporary review on the pathogenesis of takotsubo syndrome: The heart shedding tears: Norepinephrine churn and foam at the cardiac sympathetic nerve terminals

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.

The role of cardiovascular magnetic resonance in takotsubo syndrome

Takotsubo syndrome (TS) is a transient form of left ventricular dysfunction associated with a distinctive contraction pattern in the absence of significant coronary artery disease triggered by stressful events. Several aspects of its clinical profile have been described but it still remains difficult to quickly establish the diagnosis at admission.Cardiovascular magnetic resonance (CMR) has achieved great improvements in the last years, which in turn has made this imaging technology more attractive in the diagnosis and evaluation of TS. With its superior tissue resolution and dynamic imaging capabilities, CMR is currently the most useful imaging technique in this setting.In this review, we propose to comprehensively define the role of CMR in the evaluation of patients with TS and to summarize a set of criteria suitable for diagnostic decision making in this clinical setting.

Takotsubo Syndrome: Insights from Japan

We report the history and new insights of takotsubo syndrome based on the achievements that Japanese researchers have contributed and summarize the evidence originally presented from Japan. Takotsubo syndrome is a newly described heart failure characterized by transient left ventricular dysfunction. We should be aware of this entity as a syndrome, not actual cardiomyopathy. Japanese researchers focus on the experimental approaches for clinical diagnosis and treatment of takotsubo syndrome. As representatives from a country originally naming this syndrome takotsubo, a global registry for takotsubo syndrome including Japan should be established.

Echocardiographic assessment of takotsubo cardiomyopathy: beyond apical ballooning

It has been >25 years since the first report of the takotsubo cardiomyopathy (TC). Although left ventriculography was originally used to depict its typical and impressive wall motion abnormality mimicking "takotsubo", or octopus pot, echocardiography plays a pivotal role in detecting not only its left ventricular (LV) wall motion abnormality, apical ballooning, but also various other findings. First of all, apical ballooning is not an essential finding for TC anymore. Mid-ventricular LV asynergy with or without apical involvement is a basic pattern of the LV wall motion abnormality. Distribution and time course of the asynergy may be best detected by echocardiography and echo provides useful information to differentiate between TC and acute coronary syndrome or acute myocarditis. In addition to the wall motion assessment, echo detects complications of TC such as systolic anterior motion of the mitral leaflet with or without LV outflow obstruction, mitral regurgitation, LV thrombus, right ventricular (RV) involvement. In particular, RV involvement is not an uncommon finding and is associated with worse short-term as well as long-term prognosis. Finally, coronary flow measurements and speckle tracking by echo may offer additional and useful information about pathophysiology and prognosis of TC. In conclusion, echocardiography is a standard imaging modality for detecting various dynamic findings beyond apical ballooning in patients with TC.

Left ventricular outflow track obstruction and mitral valve regurgitation in a patient with takotsubo cardiomyopathy

Introduction

Takotsubo cardiomyopathy (TCM) can be complicated by left ventricular outflow tract (LVOT) obstruction and severe acute mitral regurgitation (MR), leading to hemodynamic instability in an otherwise benign disorder. Despite the severity of these complications, there is a paucity of literature on the matter. Because up to 20–25% of TCM patients develop LVOT obstruction and/or MR, it is important to recognize the clinical manifestations of these complications and to adhere to specific management in order to reduce patient morbidity and mortality. We report the clinical history, imaging, treatment strategy, and clinical outcome of a patient with TCM that was complicated with severe MR and LVOT obstruction. We then discuss the pathophysiology, characteristic imaging, key clinical features, and current treatment strategy for this unique patient population.

Case report

A postmenopausal woman with no clear risk factor for coronary artery disease (CAD) presented to the emergency department with chest pain after an episode of mental/physical stress. Physical examination revealed MR, mild hypotension, and pulmonary vascular congestion. Her troponins were mildly elevated. Cardiac catheterization excluded obstructive CAD, but revealed severe apical hypokinesia and ballooning. Notably, multiple diagnostic tests revealed the presence of severe acute MR and LVOT obstruction. The patient was diagnosed with TCM complicated by underlying MR and LVOT obstruction, and mild hemodynamic instability. The mechanism of her LVOT and MR was attributed to systolic anterior motion of the mitral valve (SAM), which the transesophageal echocardiogram clearly showed during workup. She was treated with beta-blocker, aspirin, and ACE-I with good outcome. Nitroglycerin and inotropes were discontinued and further avoided.

Conclusions

Our case illustrated LVOT obstruction and MR associated with underlying SAM in a patient with TCM. LVOT obstruction and MR are severe complications of TCM and may result in heart failure and/or pulmonary edema. Timely and accurate identification of these complications is critical to achieve optimal clinical outcomes in patients with TCM.

Current state of knowledge on Takotsubo syndrome: a Position Statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology

Takotsubo syndrome is an acute reversible heart failure syndrome that is increasingly recognized in modern cardiology practice. This Position Statement from the European Society of Cardiology Heart Failure Association provides a comprehensive review of the various clinical and pathophysiological facets of Takotsubo syndrome, including nomenclature, definition, and diagnosis, primary and secondary clinical subtypes, anatomical variants, triggers, epidemiology, pathophysiology, clinical presentation, complications, prognosis, clinical investigations, and treatment approaches. Novel structured approaches to diagnosis, risk stratification, and management are presented, with new algorithms to aid decision-making by practising clinicians. These also cover more complex areas (e.g. uncertain diagnosis and delayed presentation) and the management of complex cases with ongoing symptoms after recovery, recurrent episodes, or spontaneous presentation. The unmet needs and future directions for research in this syndrome are also discussed.

"Reverse McConnell's Sign": Interpreting Interventricular Hemodynamic Dependency and Guiding the Management of Acute Heart Failure during Takotsubo Cardiomyopathy

Although most patients with Takotsubo cardiomyopathy (TTC) have benign clinical course and prognosis, TTC can induce acute heart failure and hemodynamic instability. TTC mimics the clinical features of acute anterior wall myocardial infarction (AMI). Bedside clinicians often have a diagnostic dilemma when cardiac catheterization and angiography are either contraindicated or can cause potential adverse consequences. Misdiagnosing TTC as AMI will lead to initiation of harmful pharmacological or device-based treatment, which worsens hemodynamic compromise. Therefore, understanding and interpreting the unique pathophysiological and hemodynamic features of TTC in a better manner becomes crucial to guide effective clinical management of acute heart failure/cardiogenic shock during TTC. We review recent advances in echocardiographic diagnosis of TTC and its role in guiding bedside management of acute heart failure and cardiogenic shock, with specific focus on the interpretation of discrepant, but reciprocally dependent, left and right ventricular hemodynamics during acute stages of TTC.

Takotsubo Syndrome - Stress-induced Heart Failure Syndrome

Takotsubo syndrome has been established as an entity in the past 30 years, particularly with the introduction of interventional angiography for investigation of chest pain. Typically, it occurs in middle-aged females as a response to a stressful event, such as bad news, death, accident, natural disaster, etc. but there is not always a specific trigger. Takotsubo mimics acute myocardial infarction with electrocardiogram changes and elevated troponins. On interventional angiography the coronary arteries are normal with typical apical ballooning of the left ventricle. This feature led to its descriptive name, given by Japanese cardiologists, as the left ventricle resembles a lobster trap with a narrow neck extending into a round ventricle. This leads to a reduction in cardiac function. Takotsubo is believed to be a response to catecholamine release following a stressful event resulting in temporary myocardial damage. It usually has a benign course with spontaneous return of cardiac function. However it may recur and in a small percentage of patients can result in sudden cardiac death with arrhythmia, acute myocardial infarction and cardiac rupture. It is usually treated symptomatically depending on the severity of presentation.

Standard and advanced echocardiography in takotsubo (stress) cardiomyopathy: clinical and prognostic implications

Echocardiography is frequently the initial noninvasive imaging modality used to assess patients with takotsubo cardiomyopathy (TTC). Standard transthoracic echocardiography can provide, even in the acute care setting, useful information about left ventricular (LV) morphology as well as regional and global systolic or diastolic function. It allows the differentiation of different LV morphologic patterns according to the localization of wall motion abnormalities. A "circumferential pattern" of LV myocardial dysfunction characterized by symmetric wall motion abnormalities involving the midventricular segments of the anterior, inferior, and lateral walls should be considered suggestive of TTC and included in the differential diagnosis of acute coronary syndromes. Moreover, advanced echocardiographic techniques, including speckle-tracking, myocardial contrast, and coronary flow studies, are providing mechanistic and pathophysiologic insights into this unique syndrome. Early identification of any potential complications (i.e., LV outflow tract obstruction, reversible moderate to severe mitral regurgitation, right ventricular involvement, thrombus formation, and cardiac rupture) are crucial for the management, risk stratification, and follow-up of patients with TTC. Because of the dynamic evolution of the syndrome, comprehensive serial echocardiographic examinations should be systematically performed. This review focuses on these aspects of imaging and the increasing understanding of the clinical and prognostic utility of echocardiography in TTC.

[Tako-tsubo syndrome: analysis of a series of 60 cases]

BACKGROUND AND OBJECTIVE

The Tako-tsubo syndrome (TS) is a reversible acute cardiomyopathy simulating an infarction. We analyzed 60 patients admitted with TS in our center.

PATIENTS AND METHOD

A percentage of 73.3 were women (mean age: 70.6 ± 11.8 years); 83.3% had some cardiovascular risk factor, 25% had an anxiety-depressive disorder and in 58.3% a precipitating factor was identified, emotional stress being the most frequent. A percentage of 15.3 showed complete left bundle branch block (LBBB). In 23.3% of patients, contractile abnormalities respected the apex (mid ventricular or diaphragmatic types).

RESULTS

The anterior descending artery showed no significant lesions in 35% of patients and in 68.3% it had a diaphragmatic segment. Forty percent of patients developed heart failure (HF) and 18.3% cardiogenic shock (CS). The overall in-hospital mortality was 3.3%, while it was 8.3% among those patients who developed HF. The incidence of CS was higher among patients with LBBB (44.4 vs. 13.7%, P=.05) and males (43.8 vs. 9.1%, P=.005).

CONCLUSIONS

Although in-hospital mortality in patients admitted due to TS is low, a significant percentage of these patients develop HF with a high mortality in this subgroup. Males and patients with LBBB had higher in-hospital morbidity.

An unusual case of cardiogenic shock: common cause from uncommon etiology

Mechanical complications of an acute coronary syndrome can lead to hemodynamic instability out of proportion to the degree of left ventricular dysfunction. We present the case of a patient with cardiogenic shock secondary to severe mitral regurgitation in the setting of an acutely occluded obtuse marginal artery. Echocardiography and pathologic findings revealed an uncommon cause of anterolateral papillary muscle rupture. Using the unique features of this case, we present a clinical self-assessment exercise highlighting the challenges involved in the management of this type of patient.

Role of echocardiography in takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is characterized by transient and reversible left ventricular (LV) systolic dysfunction due to extended myocardial stunning. Despite a good long term prognosis, approximately one-third of patients with TTC experience life-threatening complications during the acute phase. Echocardiography is the first imaging modality for an early evaluation of LV systolic and diastolic function in patients with TTC. Moreover, echocardiography allows the detection of specific findings associated with TTC, such as LV outflow tract obstruction, mitral regurgitation, and right ventricular involvement, providing crucial information for clinical management and therapy and for monitoring myocardial function recovery during the follow-up.