Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience

Abstract

BackgroundSome patients with Takotsubo cardiomyopathy (TTC) develop cardiogenic shock due to left ventricular outflow tract (LVOT) obstruction – there is, however, a paucity of data regarding this condition.MethodsPrevalence, associated factors and management implications of LVOT obstruction in TTC was explored, based on two-year data from two Belgian heart centres.ResultsA total of 32 patients with TTC were identified out of 3,272 patients presenting with troponin-positive acute coronary syndrome. In six patients diagnosed with TTC (19%), a significant LVOT obstruction was detected by transthoracic echocardiography. Patients with LVOT obstruction were older and had more often septal bulging, and presented more frequently in cardiogenic shock as compared to those without LVOT obstruction (P < 0.05). Moreover, all patients with LVOT obstruction showed systolic anterior motion (SAM) of the anterior mitral valve leaflet, which was associated with a higher grade of mitral regurgitation (2.2±0.7 vs. 1.0±0.6, P<0.001). Adequate therapeutic management including fluid resuscitation, cessation of inotropic therapy, intravenous β-blocker, and the use of intra-aortic balloon pump resulted in non-inferior survival in TTC patients with LVOT obstruction as compared to those without LVOT obstruction.ConclusionsTTC is complicated by LVOT obstruction in approximately 20% of cases. Older age, septal bulging, SAM-induced mitral regurgitation and hemodynamic instability are associated with this condition. Timely and accurate diagnosis of LVOT obstruction by echocardiography is key to successful management of these TTC patients with LVOT obstruction and results in a non-inferior outcome as compared to those patients without LVOT obstruction.Electronic supplementary materialThe online version of this article (doi:10.1186/1471-2261-14-147) contains supplementary material, which is available to authorized users.

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

“…Venoarterial extracorporeal membrane oxygenation does not seem a valid option because it reduces LV preload and may even increase the LVOTO . Intra‐aortic balloon pump is also contraindicated because the afterload reduction may worsen the degree of obstruction in patients with LVOTO …”

“…14 Intra-aortic balloon pump is also contraindicated because the afterload reduction may worsen the degree of obstruction in patients with LVOTO. 12,15 The Impella assist device is a continuous, non-pulsatile, axial flow pump that provides both LV volume unloading and active circulating support by expelling aspirated blood from the LV into the ascending aorta. The use of the Impella in TTS complicated by LVOTO and severe MR has been actually reported in one single case.…”

Hemodynamic Effects, Safety, and Feasibility of Intravenous Esmolol Infusion During Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction: Results From A Multicenter Registry

“…In case of severe dehydration, fluid resuscitation may represent the main therapeutic option . However, Intra‐aortic balloon pumping, inotropes, or levosimendan infusion is relatively contraindicated in this condition, because they could worsen the dynamic gradient and thereby further jeopardize cardiac function [,].…”

Estimation of Risk Factors for Cardiogenic Shock in Takotsubo Cardiomyopathy: A Retrospective Study

“…Their use in cardiogenic shock associated with LVOTO has been suggested to allow better diastolic relaxation, better forward flow and improvement in systolic pressure (2,27,28), conversely, their role in improving short term mortality has been questioned recently (29). Similarly, the use of β-blockers to prevent recurrence has not been proven beyond doubt (2,25,30,31). Of the three patients with recurrence of TCM in our study, two had been started on β-blockers as outpatient prior to the recurrence.…”