AIM:To analyse and summarize all the articles related to positron emission tomography and Takotsubo cardiomyopathy (TTC). METHODS:We performed a systematic review of the existing literature on positron emission tomography/ nuclear imaging and Takotsubo cardiomyopathy using PUBMED database. We combined search terms such as "takotsubo", "takotsubo syndrome", "myocardial positron emission tomography", "positron emission tomography". All case reports were excluded. The list included only four articles which were reviewed by two independent investigators. It was not possible to undertake a formal meta-analysis because of the heterogeneity of the studies; therefore, we made a narrative synthesis of the collected data. RESULTS:Nuclear medicine techniques can be useful employed in the differential diagnosis of TTC from an acute coronary syndrome (ACS). In fact, transient left ventricular (LV) apical ballooning is a syndrome frequently misdiagnosed as an ACS and can mimic symptoms of myocardial infarction with ST-T segments changes on electrocardiography (ECG), a limited release of myocardial enzyme, mainly reported after sudden emotional or physical stress, and an akinesis or dyskinesis of the left ventricle apex which are completely reversible in a few weeks. In the studies included in this review, nuclear medicine techniques have demonstrated a discrepancy between normal perfusion and a reduced glucose utilization in TTC, commonly known as "inverse flow metabolism mismatch". This suggests that apical ballooning represents a transient metabolic disorder on the cellular level, rather than a structural contractile disease of the myocardium, due to a transient decrease of glucose metabolism that might be related to a coronary microcirculation impairment followed by prolonged myocardial stunning. CONCLUSION:Nuclear medicine techniques can be usefully used for the diagnosis of TTC and can increase our knowledge of the pathophysiological mechanisms of TTC. Core tip: Takotsubo cardiomyopathy is a cardiac syndrome with symptoms similar to acute myocardial infarction (MI) including chest pain and electrocardiographic changes, in absence of coronary artery stenosis. This syndrome is characterized by reversible wall-motion abnormalities involving apical and midportion of left ventricle. In the acute phase it is clinically indistinguishable from acute MI but, recently, myocardial positron emission tomography have demonstrated to delineate this syndrome from acute coronary artery disease, also offering a new pathophysiological explanation for this particular syndrome. This clinical review aimed to summarise the most significant experiences on the use of myocardial positron emission tomography in Takotsubo cardiomyopathy. SYSTEMATIC REVIEWS
The cardio-renal syndrome (CRS) includes a variety of pathologic conditions (acute or chronic) where the primary failing organ can be either the heart or the kidney. We present three cases of heart failure (HF) patients hospitalized for acute decompensation, who presented a CRS type II rapidly worsening after high doses of furosemide infusion. METHODS: From June 2015 to March 2016 all patients admitted to our Department for chronic refractory heart failure (NYHA class IV), underwent a determination of BNP and other laboratory tests (creatinine, GFR, haemoglobin), echocardiogram, non-invasive cardiac output measurement and 6 min walking test. Patients underwent a single infusion of levosimendan in case of CRS type II, at 0.1 µg/kg/min for 24-36 hours. Clinical / laboratory evaluation was repeated 24 hours and 1 week after infusion of the drug. RESULTS: Patients treated with levosimendan allowed the reduction of loop diuretics dose, because of the restoration of renal function. Body weight and peripheral edema were progressively reduced, and cardiac output improved. At discharge, exercise capacity significantly improved, functional class proved to be in NYHA class II-III, renal function and neurohormonal assessment (BNP) ameliorated. At one-month follow-up the clinical conditions remained stable as well as the parameters of renal function and plasma BNP. CONCLUSION: This clinical experience demonstrated that one of most frequent and dangerous evolution of renal impairment (development of Acute Kidney Injury) might be improved by using a single dose of levosimendan, which has a proved effect in improving cardiac function and urine output.
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