Síndrome da disfunção apical reversível (Takotsubo)

Abstract

Left ventricular systolic dysfunction is the final result of any pathological process affecting the heart in its many structures. It often results from primary muscular impairment with consequent heart failure. In this situation, myocardial damage is usually irreversible and prolonged. In some clinical situations, reversible ventricular systolic dysfunction has been well described, its prototype being the myocardial dysfunction of sepsis 1 . Recently, other situations have been reported evolving with myocardial dysfunction, also in a reversible form, but with peculiarities that distinguish them from septic dysfunction, mainly due to their characteristic clinical presentation, suggestive of acute myocardial infarction. Initially described in Japan 2 , the Takotsubo (a bottle used for trapping octopuses in Japan) syndrome or Takotsubo cardiomyopathy has been increasingly identified in daily clinical practice, including its important complications 3 . We report a case of that syndrome in a patient with respiratory failure of muscular etiology, which evolved with cardiogenic shock. Case ReportThe patient was a 64-year-old male with myasthenia gravis for 1 year, an ex-smoker, who had quit smoking 20 years earlier and had a familial history of coronary artery disease. The patient, who regularly used pyridostigmine, was hospitalized due to worsening of his neurological disease, with intense and generalized muscular weakness and clinical and gasometrical signs of hypoventilation.Initially, the patient underwent plasmapheresis sessions, with no significant improvement. At the ward, he experienced chest discomfort and worsening of the dyspnea, being transferred to the intensive care unit, where he underwent electrocardiography that showed an ST segment elevation of approximately 2 mm from V1 to V6 with amputated R from V1 to V6 ( fig. 1A).Blood gas analysis showed significant hypoventilation (PCO 2 = 105 mm Hg) with severe respiratory acidosis (PH=7.07; HCO 3 = 29.9 mEq/L). The electrolytes and renal function were normal; troponin I was 5.0 ng/dL (Nl=up to 1.0 ng/dL); and CKMb was 22 ng/dL (N=up to 3 ng/dL). The patient was intubated, put under mechanical ventilation, and underwent emergency cine coronary angiography. The examination showed that the left main coronary artery, the anterior descending artery, and the right coronary artery had no significant atherosclerotic lesions, and the left marginal branch of the circumflex artery had a 60% atherosclerotic lesion ( fig. 2). The left ventricle had akinesia of the anteroapical wall and an ejection fraction of 33% ( fig.3) The patient evolved with arterial hypotension, which required 0.3 µg/kg/min of noradrenaline. A catheter was passed through the pulmonary artery, showing a cardiac index of 2.1 L/min and a pulmonary artery occlusion pressure of 12 mm Hg. On that occasion, his arterial lactate level was 31 mg/dL (normal, up to 22 mg/dL), the electrocardiogram showed an inactive zone from V1 to V6 (fig. 1B), and the echocardiogram showed apical dyskinesia, akinesia of the ...

Emotional stress as a trigger of myasthenic crisis and concomitant takotsubo cardiomyopathy: a case report

“…Both patients in those reports were initially admitted for MG crisis, without any identified psychological stress, and subsequently developed TC following plasmapheresis treatments. Both reports suggested that the MG crisis itself and/or plasmapheresis treatments played a causative role in the development of TC [5,6]. In contrast, our patient with a recent diagnosis of MG presented with TC after major emotional stress which was shortly followed by MG crisis.…”

Takotsubo syndrome in patients with myasthenia gravis: a systematic review of previously reported cases

“…There were 13 (81%) female patients. According to this review, the first case reported on MG associated TTS was by Sousa JMA et al in 2005 from Brazil [50]. The latest report was from Austria by Finsterer J et al in 2018 [22].…”

Reverse Takotsubo Cardiomyopathy from Myasthenic Crisis: A Case Report

“…This is the first case report, to the authors' knowledge, of MG and RTCM. An existing PUBMED review of the literature by the authors found only 8 cases of TCM and MG with no incidence of RTCM and MG until now (Table 2) [4][5][6][7][8][9][10][11]. The average age of stress induced cardiomyopathy (TCM and RTCM) was 68 with the majority of patients being female (female to male ratio of nine to one).…”