Takotsubo Cardiomyopathy: Understanding the Pathophysiology of Selective Left Ventricular Involvement

Takotsubo Syndrome: The Secret Crosstalk between Heart and Brain

An acute, transient episode of left ventricular dysfunction characterizes Takotsubo syndrome. It represents about 2% of all cases of acute coronary syndrome (ACS), and occurs predominantly in postmenopausal women, generally following a significant physical or emotional stressor. It can be diagnosed based on clinical symptoms and the absence of coronary artery disease on angiography. Ventriculography remains the gold standard for the diagnosis. Despite its transitory characteristic Takotsubo syndrome should not be considered a benign condition since complications occur in almost half of the patients, and the mortality rate reaches 4-5%. Lately, it has been revealed that Takotsubo syndrome can also lead to permanent myocardial damage due to the massive release of catecholamines that leads to myocardial dysfunction. Different mechanisms have been advanced to explain this fascinating syndrome, such as plaque rupture and thrombosis, coronary spasm, microcirculatory dysfunction, catecholamine toxicity, and activation of myocardial survival pathways. Here are still several issues with Takotsubo syndrome that need to be investigated: the complex relationship between the heart and the brain, the risk of permanent myocardial damage, and the impairment of cardiomyocyte. Our review aims to elucidate the pathophysiology and the mechanisms underlying this complex disease to manage the diagnostic and therapeutic algorithms to create a functional synergy between physicians and patients.

Takostubo syndrome combined with ventricular septal perforation: a case report

Background

The precise clinical features and etiologic basis of Takotsubo syndrome remain unclear, although an association with emotional or stressful triggers has been recognized. Ventricular septal perforation is a very rare life-threatening complication.

Case presentation

A 77-year-old female patient presented to the hospital with unrelieved chest tightness and shortness of breath. Three months ago, the patient's electrocardiogram revealed ischemic T wave inversion of the anterior wall, along with an increase in myocardial injury markers. There was no evidence of a ventricular septal defect on echocardiography. The patient was admitted to the respiratory department to treat lung lesions. The electrocardiogram demonstrated dynamic changes following admission, and the myocardial markers returned to normal, but the echocardiography revealed a ventricular septal defect. The initial diagnosis was ventricular septal perforation because of myocardial infarction with acute anterior ST-segment elevation. Coronary angiography revealed no abnormalities, but left ventricular angiography revealed an enlarged apex and VSD, with a right ventricular shunt bundle. Later, cardiac MRI revealed an apical ventricular septal defect. Further inquiry of the patient's medical history revealed that her husband died unexpectedly three months ago, and her daughter was seriously injured in a car accident, causing the patient severe emotional distress. Takotsubo syndrome was then determined in conjunction with the patient's medical history, symptoms, signs, and pertinent examinations. Without using a catheter or a surgical procedure, we managed the patient's medical condition. Two weeks later, the patient was discharged with symptoms improved.

Conclusions

Takotsubo syndrome is comparable to an acute myocardial infarction on clinical and electrocardiographic examination in the absence of significant coronary disease. Although ventricular septal perforation is most commonly associated with acute myocardial infarction, it can also happen following Takotsubo syndrome. Takotsubo syndrome complicated by ventricular septal perforation is easily misdiagnosed. The early recognition and management of this condition can avoid or reduce morbidity and mortality.

Left Ventricular Free Wall Rupture in Broken-Heart Syndrome: A Fatal Complication

Takotsubo cardiomyopathy is usually a transient condition and is treated conservatively. It is rarely associated with ventricular free wall rupture, a fatal complication of the disease described in this report. Cardiothoracic surgery performed emergent ventricular wall repair; however, treatment was unsuccessful, and the patient expired.

Diagnosis and prognosis of myocardial infarction in a patient without obstructive coronary artery disease during bronchoscopy: a case study and literature review

Background

It is increasingly recognized that a significant proportion of patients suffered from acute myocardial infraction (AMI) who did not have obstructive coronary artery disease (≥50% diameter stenosis). The term “MINOCA (myocardial infarction with nonobstructive coronary arteries)” was coined for such entity, however, the exact mechanism of MINOCA is still unclear. Herein, we report a patient with MINOCA during bronchoscopy and further review the recent literature.

Case presentation

A 65-year-old woman was hospitalized with the main complaint of chest tightness, nausea and vomiting for 30 min during bronchoscopy under local anesthesia. Immediate electrocardiogram (ECG) showed ST-segments elevation in leads V2–6 compared with those at admission, and the further evolvement of leads V2–3 into pathological Q wave. Serum cardiac biomarkers revealed high-sensitive cardiac troponin T (hs-cTnT) levels of 20.12 ng/L and 674.6 ng/L at the peak (normal range 0-14 ng/L). Emergency coronary angiography (CAG) showed only approximate 30% stenosis in the left anterior descending (LAD) ostium and 40% stenosis in the first diagonal branch (D1), with quantitative flow ratio (QFR) value for LAD of 0.96. Moreover, her echocardiographic examination presented new significant abnormal wall motion (anterior ventricular wall) with an estimated left ventricular ejection fraction (LVEF) of 62.1% after the cardiac attack. Thoracic enhanced CT scanning indicated no obvious sign of pulmonary embolism. Therefore, with confirmed AMI and the absence of significant coronary stenosis simultaneously, MINOCA was diagnosed with the prescription of dual-antiplatelet, statins, beta-blocker, angiotensin receptors antagonist, calcium channel blocker and nitrate. This patient had a good prognosis during a follow-up of 14 months.

Conclusion

In this case, bronchoscopy might have caused extremely tense and anxious which led to a sympathetic hyperfunction and acute coronary thrombosis induced by plaque disruption and coronary artery spasm. QFR value is a feasible technique to evaluate the functional coronary stenosis and assist the diagnose of MINOCA. Also, the diagnosis of MINOCA deems an exploration of underlying causes for proper management and prognostic evaluation.