Impact of transpulmonary thermodilution-based cardiac contractility and extravascular lung water measurements on clinical outcome of patients with Takotsubo cardiomyopathy after subarachnoid hemorrhage: a retrospective observational study

Abstract

IntroductionTakotsubo cardiomyopathy (TCM) is a life-threatening systemic consequence early after subarachnoid hemorrhage (SAH), but precise hemodynamics and related outcomes have not been studied. The purpose of this study was to investigate TCM-induced cardiac function by transpulmonary thermodilution and its impact on clinical outcome of SAH.MethodsWe retrospectively analyzed 46 consecutive postoperative SAH patients who developed TCM. Patients were divided into two groups of echocardiographic left ventricular ejection fraction (LVEF) <40% (TCM with left ventricular (LV) dysfunction) and LVEF ≥40% (TCM without LV dysfunction). Cardiac function index (CFI) and extravascular lung water index (ELWI) were monitored by transpulmonary thermodilution in parallel with serial measurements of echocardiographic parameters and blood biochemical markers.ResultsTranspulmonary thermodilution-derived CFI was significantly correlated with LVEF (r = 0.82, P < 0.0001). The CFI between days 0 and 7 was significantly lower in patients with LV dysfunction (LVEF <40%) than in patients with LVEF ≥40% (P < 0.05). CFI had a better ability than cardiac output to detect cardiac dysfunction (LVEF <40%) (area under the curve = 0.85 ± 0.02; P < 0.001). A CFI value <4.2 min−1 had a sensitivity of 82% and specificity of 84% for detecting LVEF <40%. CFI <4.2 min−1 was associated with delayed cerebral ischemia (DCI) (odds ratio (OR) = 2.14, 95% confidence interval (CI) = 1.33 to 2.86; P = 0.004) and poor 3-month functional outcome on a modified Rankin Scale of 4 to 6 (OR = 1.87, 95% CI = 1.06 to 3.29; P = 0.02). An extravascular lung water index (ELWI) >14 ml/kg after day 4 increased the risk of poor functional outcome at 3-month follow-up (OR = 2.10, 95% CI = 1.11 to 3.97; P = 0.04).ConclusionsProlonged cardiac dysfunction and pulmonary edema increased the risk of DCI and poor 3-month functional outcome in postoperative SAH patients with TCM. Serial measurements of CFI and ELWI by transpulmonary thermodilution may provide an easy bedside method of detecting early changes in cardiopulmonary function to direct proper post-SAH treatment.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-014-0482-4) contains supplementary material, which is available to authorized users.

Acute cardiac support with intravenous milrinone promotes recovery from early brain injury in a murine model of severe subarachnoid haemorrhage

“…The therapeutic approach of MIL‐mediated cardiac support used here is clinically relevant because we employed an established protocol to reverse DCI without adverse cardiopulmonary complications . In fact, at this dose range (0.25‐0.75 μg/kg/min) no animals died during postconditioning or presented MRI‐evidenced rebleeding on final examination (Figure B), which is in good agreement with our previous findings using dobutamine .…”

“…It is noteworthy that post‐SAH cardiac depression observed clinically was reproducible in the severe grades of our mouse SAH model. In this study, we focused on immediate cardiac support with the inotrope MIL during postconditioning in hopes of coupling a potential neuronal postconditioning protocol to the manipulation of CBF (Figures and ).…”

Subarachnoid bleeding triggering Takotsubo syndrome

“…Mortality in this study was higher and functional outcome (Barthel index) worse in SAB patients with TTS as compared to SAB patients without TTS [6]. In a retrospective study of 46 SAB-triggered TTS patients the risk for ischemic stroke was increased among those with reduced systolic function [7]. In a study of 300 patients with SAB, 45 (15%) had neurogenic stress cardiomyopathy [8].…”

Preceding functional tooth loss delays recovery from acute cerebral hypoxia and locomotor hypoactivity after murine subarachnoid haemorrhage

“…In general, molar crown‐less condition induces a reduction in sensory input from receptors linked to mastication and mastication‐associated face and jaw movements to the somatic sensory cortex, which is involved in neural circuits in the amygdala and hippocampus . In addition, mastication under stressful conditions attenuates stress‐induced increases in plasma corticosterone and catecholamines either via the hypothalamic‐pituitary‐adrenal axis or autonomic nervous system, as well as the expression of stress‐related substances, such as neurotrophic factors and nitric oxide, can contribute to exacerbate pathophysiological conditions following severe SAH …”

“…17,18 In addition, mastication under stressful conditions attenuates stress-induced increases in plasma corticosterone and catecholamines either via the hypothalamic-pituitary-adrenal axis or autonomic nervous system, 17,19 as well as the expression of stress-related substances, such as neurotrophic factors and nitric oxide, can contribute to exacerbate pathophysiological conditions following severe SAH. [20][21][22][23][24][25] This study has some limitations that warrant further investigation.…”