Takotsubo Cardiomyopathy (Acute Left Ventricular Apical Ballooning Syndrome) Occurring in the Intensive Care Unit

Haghi, Dariusch; Fluechter, Stephan; Süselbeck, Tim; Saur, Joachim; Bheleel, Osama; Borggrefe, Martin; Papavassiliu, Theano

doi:10.1007/s00134-006-0111-z

Cited by 45 publications

(36 citation statements)

References 21 publications

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“…In these situations, TTC may manifest as arrhythmia, hypotension, acute pulmonary edema, abnormal ECG, or troponin elevation. 37,38 Triggers A hallmark of TTC is its frequent association with a triggering stressful event. In early reports, most of these events involved emotional trauma.…”

Section: Clinical Profilesmentioning

confidence: 99%

Epidemiology and Clinical Profile of Takotsubo Cardiomyopathy

Sharkey

Maron

2014

Circ J

110

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Section: Clinical Profilesmentioning

confidence: 99%

Epidemiology and Clinical Profile of Takotsubo Cardiomyopathy

Sharkey

Maron

2014

Circ J

110

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“…ST elevation is noted in 11-90%, pathological Q wave in 6-31%, T wave inversions (TWI) in 16-100%, and QTc prolongation in 56-100% of patients [4,7,20,21]. Leads V 3 -V 6 were the most common sites for ST elevation or TWI and the estimated EKG sensitivity for ST segment and T wave changes is 19% [7,8,22].…”

Section: Clinical Presentation and Diagnosismentioning

confidence: 98%

Transient Left Ventricular Apical Ballooning in a Postmenopausal Woman with Chronic Liver Disease, Malignancy, and Recent Ischemic Stroke: A Case Report and Review of the Literature

Covell¹,

Clendenen

2012

ISRN Vascular Medicine

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Transient left ventricular apical ballooning (TLVAB), or Takotsubo cardiomyopathy, is a poorly understood phenomenon that is thought to be related to a surge of catecholamines under stress conditions that causes microvascular dysfunction and a unique pattern of myocardial stunning. TLVAB occurs in two distinct patient populations: (i) community presentation similar to acute coronary syndrome and (ii) the critically ill. Understanding the differences in presentation, prognosis and management between these two groups may improve the outcome. We present a case of TLVAB developing in a Caucasian postmenopausal female who developed TLVAB suddenly on a background of chronic liver disease, malignancy, and recent ischemic stroke. The patient presented with hemodynamic collapse and was treated with inotropes, vasopressors, and supportive care until cardiac function improved. Additionally, we review the current literature describing the risk factors, pathophysiology, and treatment of TLVAB. Case ReportA 58-year-old postmenopausal woman presented to the emergency department with a sudden onset of weakness associated with dyspnea, peripheral cyanosis, and bilateral lower extremity edema that progressed over one to two hours to include a decreased level of consciousness. In the emergency department, she was noted to be hypotensive and hypoxic. She was emergently intubated and admitted to the critical care unit. She has no significant medical history, but she reported a 25-pack-year history of smoking and drinks approximately 50 to 60 units of alcohol per week. Laboratory investigations revealed leukocytosis, thrombocytopenia, and evidence of chronic liver disease. Toxicology screen was negative for cocaine. EKG on admission was significant only for sinus tachycardia and QT prolongation. During the course of two days, the patient developed mild ST segment elevation in V 1 and T-wave inversions in leads avL, I, and V 1 . No pathological Q waves were noted. Imaging revealed no acute intracranial hemorrhage; however, changes consistent with recent ischemic stroke were present. Additional imaging demonstrated the presence of abdominal ascites, anasarca, and a right sided pleural effusion with left upper lobe mass suspicious for malignancy. Transthoracic echocardiography demonstrated akinetic apex, hypokinetic mid-left ventricular, and hyperkinetic basal left ventricular segments (Figure 1). Left ventricular ejection fraction was 20-25% and moderate mitral regurgitation with concomitant left atrial enlargement was noted. Cardiac enzyme peak levels were measured with a troponin of 4.92 and CK-MB of 18 (17.5% of total CPK). Biopsy of the lung masses revealed malignancy. During the acute phase of her presentation, the patient received norepinephrine and dobutamine to augment cardiac output until her TLVAB resolved. Definition and EpidemiologyTakotsubo cardiomyopathy was originally described by Dote et al. in the early 1990s [1]. Takotsubo cardiomyopathy

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“…Published studies 4 indicate that TC is not an uncommon finding among patients admitted to the intensive care unit, and unless specifically sought echocardiographically, it can be missed.…”

Section: Behnes Et Al Takotsubo In Heart Transplantation E63mentioning

confidence: 99%

Biventricular Takotsubo Cardiomyopathy in a Heart Transplant Recipient

et al. 2013

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A 64-year-old man who had undergone cardiac transplantation for ischemic cardiomyopathy 9 years earlier was admitted to the hospital for malaise and fever of unknown origin. His posttransplantation course had been complicated by transplant vasculopathy requiring percutaneous coronary intervention 2 years earlier. His immunosuppressant regimen included cyclosporine, mycophenolate mofetil, and low-dose steroids. On admission, he denied having chest pain, but his high-sensitivity troponin I level was elevated at 17 µg/L (normal range, 0-0.045 µg/L). His ECG was unremarkable. Echocardiography demonstrated extensive posterior wall akinesia but no other regional wall motion abnormalities. Ejection fraction was estimated at 60%. Urgent coronary angiography demonstrated subtotal occlusion of the left circumflex artery. Appropriate antibiotic therapy was initiated, and possible sources of infection were ruled out by transesophageal echocardiography and thoracoabdominal computed tomography scan. Two days later, the patient was taken back to the catheterization laboratory and treated by implantation of a drug-eluting stent.One week later, while still in the hospital, he developed sudden onset of dyspnea accompanied by a drop in oxygen saturation and was admitted to the intensive care unit. His chest x-ray demonstrated pulmonary venous congestion. His aminoterminal pro-brain natriuretic peptide was markedly increased at 40 499 ng/mL (normal range, 0-125 ng/mL). The patient´s cardiac enzymes were as follows: high-sensitivity troponin I, 6.368 µg/L (normal range, 0-0.045 µg/L); creatine phosphokinase, 207 U/L (normal range, 35-171 U/L); and isoenzyme creatine phosphokinase-MB, 22 U/L (normal range, 0-24 U/L). Urgent echocardiography revealed severe akinesia/dyskinesia of the mid and apical portions of both ventricles (Movies I and II in the online-only Data Supplement). Three-dimensional echocardiography performed 1 day later confirmed these findings (Figure [A]). Significant coronary artery obstruction was excluded by repeat coronary angiography (Figure [B]). His ECG demonstrated new T-wave inversions in leads I, II, aVL, aVF, and V 3 through V 6 (Figure [C]). Follow-up echocardiography 10 days later (Movies III and IV in the online-only Data Supplement) showed reversal of all wall motion abnormalities except for posterior wall akinesia/dyskinesia (Figure [D]).Takotsubo cardiomyopathy (TC) is characterized by an acute reversible dysfunction of the myocardium unrelated to obstructive coronary artery disease or myocarditis.Disturbances of myocardial microcirculation and increased sympathetic activity caused by excessive local release of catecholamines (ie, epinephrine, norepinephrine, and dopamine), which in turn may lead to microvascular spasms or myocyte injury, have been implicated in the pathophysiology of this disease entity. 1To the best of our knowledge, our case is the first description of spontaneously occurring biventricular TC in a heart transplantation patient. There is only 1 other report in the literature of TC o...

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Takotsubo Cardiomyopathy (Acute Left Ventricular Apical Ballooning Syndrome) Occurring in the Intensive Care Unit

Cited by 45 publications

References 21 publications

Epidemiology and Clinical Profile of Takotsubo Cardiomyopathy

Epidemiology and Clinical Profile of Takotsubo Cardiomyopathy

Transient Left Ventricular Apical Ballooning in a Postmenopausal Woman with Chronic Liver Disease, Malignancy, and Recent Ischemic Stroke: A Case Report and Review of the Literature

Biventricular Takotsubo Cardiomyopathy in a Heart Transplant Recipient

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