Morphologically Unique Feature of Recurrent Ampulla (Takotsubo) Cardiomyopathy

Abstract

mpulla (takotsubo) cardiomyopathy is a novel heart syndrome characterized by transient left ventricular (LV) dysfunction, mimicking acute myocardial infarction. 1,2 Guidelines for the diagnosis of ampulla cardiomyopathy were recently established in Japan. 3 We report 2 rare cases of recurrent ampulla cardiomyopathy. Both patients experienced typical ampulla cardiomyopathy at the initial admission and atypical ampulla cardiomyopathy at the second admission. We diagnosed the transient LV apical ballooning as typical ampulla cardiomyopathy and the other types of transient LV ballooning as atypical ampulla cardiomyopathy in accordance with the guidelines. Case Reports Case 1A 55-year-old woman with a history of rhabdomyolysis was admitted to the Department of Internal Medicine because of severe general fatigue, vomiting and weakness of the extremities related to recurrent rhabdomyolysis. She did not have chest oppression or dyspnea at the initial admission. At that time, her pulse rate was 127 beats/min, blood pressure 130/79 mmHg, and temperature 36.4°C. The leukocyte count was elevated at 11,800/ μl. The serum levels of aspartate aminotransferase (AST) (208 IU/L), lactate dehydrogenase (LDH) (840 IU/L), creatine kinase (CK) (7,972 IU/L), CK-MB (68 IU/L) and C-reactive protein (CRP) (6.2 mg/dl) were also elevated. Electrocardiogram (ECG) revealed sinus rhythm and T-wave inversion in leads II, III, aVF and V3-6 with prolongation of the QT interval (QTc 0.52 ms) (Fig 1B). Transthoracic echocardiography on admission revealed akinesis of the left ventricle, except in the basal region (ejection fraction 41%) (Fig 2A). She recovered 4 weeks later and was discharged because her general condition had improved with treatment for rhabdomyolysis and repeat echocardiography showed normalization of LV wall motion. The T wave inversion and the QT interval also normalized before discharge.One month later, she again experienced general fatigue, vomiting, weakness of the extremities again because of recurrent rhabdomyolysis, but she also had chest oppression and dyspnea. The leukocyte count was elevated (21,600/ μl), as were the serum levels of AST (166 IU/L), LDH (709 IU/L), CK (2,713 IU/L), CK-MB (108 IU/L), CRP (5.9 mg/dl) and noradrenalin (NA) (1,492 pg/ml). ECG on admission revealed sinus rhythm and T-wave inversion in leads V1-3 with prolongation of the QT interval (QTc 0.50 ms) (Fig 1C). Transthoracic echocardiography on admission revealed a hypercontractile LV apex with an akinetic basal-to mid-LV (ejection fraction 43%) (Fig 2B). Urgent coronary angiography (CAG) did not reveal a significant stenotic lesion. Computed tomography of the abdomen and iodine-131-metaiodobenzylguanidine (MIBG) scintigraphy did not show pheochromocytoma. Her acute heart failure was medically treated, she recovered and was discharged. Case 2A 75-year-old man with a history of bronchial asthma was admitted to a nearby hospital because of worsening cough and dyspnea. He was treated with intravenous the- (Received December 2, 2007; revised manuscript...

Recurrent takotsubo cardiomyopathy can appear as transient midventricular ballooning syndrome

“…Although recurrence of takotsubo cardiomyopathy is known to be rare [3], there are some reports of recurrent cases showing atypical patterns of left ventricular contraction. Furthermore, there are cases similar to the one reported here, in which good contractions of the apex and base have been observed during the second attack [4,5]. Transient midventricular ballooning syndrome has been described as an atypical form of takotsubo cardiomyopathy [6] and our case at the second admission can be classified into this syndrome.…”

Comparison of Electrocardiographic Findings Between the Midventricular Ballooning Form and Apical Ballooning Form of Takotsubo Cardiomyopathy

“…10 Ikeda et al also reported 2 cases in which initial ECG showed only T wave inversion in leads V1 to V3. 11 In this study, ECG changes including ST segment elevation and/or T wave inversion were found mainly in leads V2 to V3, and were never found in lead V5 in midventricular ballooning. According to previous reports and our results, apical wall motion is intact in midventricular ballooning, and ECG changes are rare in leads V4 to V5, which reflect the distal portion of the left ventricular chamber.…”

Epidemiology, pathogenesis, and management of takotsubo syndrome

“…The apical-sparing patterns in midventricular and basal types of TS argue against aborted myocardial infarction in a long wrap-around LAD as a cause of TS. The apical-sparing patterns also argue against myocardial bridging with systolic compression of LAD as a cause [ 29 – 31 ]. Furthermore, in 73% of patients with TS, the course of LAD does not fulfil the criteria of long wrap-around LAD [ 32 ].…”