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Post-Procedural Inverted Takotsubo Cardiomyopathy
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Post-Procedural Inverted Takotsubo Cardiomyopathy Jackson J. Liang, DO a,∗ , Andrew K. Kurklinsky, MD b , Tyler J. Peterson, MD b , William K. Freeman, MD b and Jae K. Oh, MD b a b
Department of Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA Division of Cardiovascular Diseases, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA
Keywords. Takotsubo cardiomyopathy; Stress cardiomyopathy; Apical ballooning syndrome; Acute coronary syndrome; Echocardiography
A
72 year old-woman with rheumatoid arthritis was admitted to the hospital for evaluation of dyspnoea. CT scan of the chest revealed bilateral pulmonary nodules. Shortly after bronchoscopy with transbronchial biopsy, she developed anxiety, diaphoresis, dyspnoea, and tachycardia. Initial troponin T was elevated. Due to concern for procedural myocardial infarction (MI), aspirin, clopidogrel and heparin were administered. Transthoracic echocardiogram (TTE) (Fig. 1; Movie 1) showed regional wall abnormalities confined to the basal left ventricle (LV) with focal basal LV dilation. Findings were atypical for coronary artery disease and consistent with the basal variant of stress cardiomyopathy (inverted Takotsubo cardiomyopathy). She was given lisinopril, metoprolol, and anxiolytics. Her symptoms resolved and 6-h troponin T trended downwards. Repeat TTE one month later (Fig. 2; Movie 2) showed marked
improvement in LV basal function, consistent with the diagnosis of inverted Takotsubo cardiomyopathy.
Comments Stress-induced cardiomyopathy (also known as Takotsubo cardiomyopathy or apical ballooning syndrome) involves transient, reversible LV dysfunction in the absence of significant obstructive coronary artery disease. It typically develops after severe physical or emotional affliction. It most frequently occurs in post-menopausal women, as in our patient. Patients present with a clinical picture similar to that of MI with chest pain, dyspnoea, ST-changes on electrocardiogram, and cardiac biomarker elevation. Takotsubo cardiomyopathy most commonly involves apical ballooning with basal sparing [1]. Right ventricular involvement occurs in one quarter of patients
Fig. 1. (A) Systolic and (B) diastolic frames of a TTE (apical two-chamber view) show significant regional wall motion abnormalities during systole confined to the basal LV with focal basal LV dilation, consistent with the basal variant of stress cardiomyopathy. Received 25 March 2013; accepted 12 April 2013; available online 14 May 2013 ∗
Corresponding author at: Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA. Tel.: +1 507 584 2511; fax: +1 507 266 0036. E-mail address: [email protected] (J.J. Liang).
© 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2013.04.108
Liang et al. Reverse Takotsubo
1061 IMAGE
Heart, Lung and Circulation 2013;22:1060–1061
Fig. 2. (A) Systolic and (B) diastolic frames of a TTE (apical two-chamber view) at follow-up visit one month later show marked improvement of the basal LV wall motion abnormalities.
and is associated with haemodynamic instability and longer hospitalisation. Three variant forms have been identified: (1) inverse or reverse, which exhibits basal akinesis with hyperdynamic apex, (2) mid-ventricular, (3) localised. Patients with the inverse variant are typically younger and are more likely to have preceding physical or emotional distress [2]. This case illustrates the importance of considering stress cardiomyopathy and its variants in the differential diagnosis of post-procedural MI.
Acknowledgements The authors have no conflicts of interest or financial disclosures. There were no sources of funding for this project.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.hlc.2013.04.108.
References [1] Elesber AA, Prasad A, Bybee KA, Valeti U, Motiei A, Lerman A, et al. Transient cardiac apical ballooning syndrome: prevalence and clinical implications of right ventricular involvement. J Am Coll Cardiol 2006;47(5):1082–3. [2] Ramaraj R, Movahed MR. Reverse or inverted takotsubo cardiomyopathy (reverse left ventricular apical ballooning syndrome) presents at a younger age compared with the mid or apical variant and is always associated with triggering stress. Congest Heart Fail 2010;16(6):284–6.
Image
Post-Procedural Inverted Takotsubo Cardiomyopathy Jackson J. Liang, DO a,∗ , Andrew K. Kurklinsky, MD b , Tyler J. Peterson, MD b , William K. Freeman, MD b and Jae K. Oh, MD b a b
Department of Internal Medicine, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA Division of Cardiovascular Diseases, Mayo Clinic, 200 1st Street SW, Rochester, MN, USA
Keywords. Takotsubo cardiomyopathy; Stress cardiomyopathy; Apical ballooning syndrome; Acute coronary syndrome; Echocardiography
A
72 year old-woman with rheumatoid arthritis was admitted to the hospital for evaluation of dyspnoea. CT scan of the chest revealed bilateral pulmonary nodules. Shortly after bronchoscopy with transbronchial biopsy, she developed anxiety, diaphoresis, dyspnoea, and tachycardia. Initial troponin T was elevated. Due to concern for procedural myocardial infarction (MI), aspirin, clopidogrel and heparin were administered. Transthoracic echocardiogram (TTE) (Fig. 1; Movie 1) showed regional wall abnormalities confined to the basal left ventricle (LV) with focal basal LV dilation. Findings were atypical for coronary artery disease and consistent with the basal variant of stress cardiomyopathy (inverted Takotsubo cardiomyopathy). She was given lisinopril, metoprolol, and anxiolytics. Her symptoms resolved and 6-h troponin T trended downwards. Repeat TTE one month later (Fig. 2; Movie 2) showed marked
improvement in LV basal function, consistent with the diagnosis of inverted Takotsubo cardiomyopathy.
Comments Stress-induced cardiomyopathy (also known as Takotsubo cardiomyopathy or apical ballooning syndrome) involves transient, reversible LV dysfunction in the absence of significant obstructive coronary artery disease. It typically develops after severe physical or emotional affliction. It most frequently occurs in post-menopausal women, as in our patient. Patients present with a clinical picture similar to that of MI with chest pain, dyspnoea, ST-changes on electrocardiogram, and cardiac biomarker elevation. Takotsubo cardiomyopathy most commonly involves apical ballooning with basal sparing [1]. Right ventricular involvement occurs in one quarter of patients
Fig. 1. (A) Systolic and (B) diastolic frames of a TTE (apical two-chamber view) show significant regional wall motion abnormalities during systole confined to the basal LV with focal basal LV dilation, consistent with the basal variant of stress cardiomyopathy. Received 25 March 2013; accepted 12 April 2013; available online 14 May 2013 ∗
Corresponding author at: Mayo Clinic, 200 1st Street Southwest, Rochester, MN 55905, USA. Tel.: +1 507 584 2511; fax: +1 507 266 0036. E-mail address: [email protected] (J.J. Liang).
© 2013 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier Inc. All rights reserved.
1443-9506/04/$36.00 http://dx.doi.org/10.1016/j.hlc.2013.04.108
Liang et al. Reverse Takotsubo
1061 IMAGE
Heart, Lung and Circulation 2013;22:1060–1061
Fig. 2. (A) Systolic and (B) diastolic frames of a TTE (apical two-chamber view) at follow-up visit one month later show marked improvement of the basal LV wall motion abnormalities.
and is associated with haemodynamic instability and longer hospitalisation. Three variant forms have been identified: (1) inverse or reverse, which exhibits basal akinesis with hyperdynamic apex, (2) mid-ventricular, (3) localised. Patients with the inverse variant are typically younger and are more likely to have preceding physical or emotional distress [2]. This case illustrates the importance of considering stress cardiomyopathy and its variants in the differential diagnosis of post-procedural MI.
Acknowledgements The authors have no conflicts of interest or financial disclosures. There were no sources of funding for this project.
Appendix A. Supplementary data Supplementary data associated with this article can be found, in the online version, at http://dx.doi.org/10.1016/j.hlc.2013.04.108.
References [1] Elesber AA, Prasad A, Bybee KA, Valeti U, Motiei A, Lerman A, et al. Transient cardiac apical ballooning syndrome: prevalence and clinical implications of right ventricular involvement. J Am Coll Cardiol 2006;47(5):1082–3. [2] Ramaraj R, Movahed MR. Reverse or inverted takotsubo cardiomyopathy (reverse left ventricular apical ballooning syndrome) presents at a younger age compared with the mid or apical variant and is always associated with triggering stress. Congest Heart Fail 2010;16(6):284–6.