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Tako-Tsubo cardiomyopathy mimicking acute aortic dissection: A case report
International Journal of Cardiology 145 (2010) e68 – e69 www.elsevier.com/locate/ijcard
Letter to the Editor
Tako-Tsubo cardiomyopathy mimicking acute aortic dissection: A case report Hendrik B. Sager ⁎, Heribert Schunkert, Volkhard Kurowski Medizinische Klinik II, Universität zu Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany Received 12 October 2008; accepted 14 December 2008 Available online 30 January 2009
Abstract Tako-Tsubo cardiomyopathy is characterized by a transient and reversible left ventricular dysfunction possibly due to a catecholaminemediated myocardial stunning. This form of cardiomyopathy is rarely associated with cardiogenic shock. Here we report on a patient with Tako-Tsubo cardiomyopathy induced low output failure in which blood flow disturbances in the thoracic aorta mimicked an acute type A aortic dissection. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Tako-Tsubo cardiomyopathy; Cardiogenic shock; Aortic dissection; Stress-induced cardiomyopathy; Transient apical ballooning syndrome
Transient left ventricular dysfunction, also termed TakoTsubo cardiomyopathy, has recently been recognized as a novel entity within the spectrum of acute coronary syndromes and affects approximately 1% of patients with a positive troponin [1]. It is especially seen in post-menopausal women after sudden emotional or physical stress [2,3]. Despite its increasing clinical awareness, the underlying pathophysiological mechanisms remain unclear. A few reports have suggested that the syndrome represents a form of catecholamine-induced acute myocardial stunning, with a predilection for the cardiac apex [4]. A 60-year-old woman presented in a nearby hospital with sudden onset of epigastric pain. Laboratory tests revealed elevated cardiac biomarkers (troponin T 1 µg/L, CK 390 U/L, CKMB 75 U/L). The ECG exhibited sinus rhythm with a right bundle branch block, Twave inversions in right precordial leads and horizontal ST segment depression located inferolaterally. The patient underwent cardiac catheterization revealing no stenosis or intraluminal thrombus. Left ventriculogram showed a markedly depressed ventricular function with mid-ventricular akinesia and preserved systolic contractility only of the apical and basal segments (movie is provided as Supplementary
Movie 1 online). During coronary angiography a prominent staining with contrast medium was observed at the inner curvature of the ascending aorta that was confirmed by aortography (Fig. 1, two movies are provided as Supplementary
⁎ Corresponding author. Tel.: +49 451 500 2421; fax: +49 451 500 2363. E-mail address: [email protected] (H.B. Sager).
Fig. 1. Withhold of contrast medium (arrows) in the ascending aorta after aortography.
0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.12.157
H.B. Sager et al. / International Journal of Cardiology 145 (2010) e68–e69
69
myopathy should be considered. Tako-Tsubo cardiomyopathy can occasionally lead to cardiogenic shock [2,5] which may result in abnormal aortic contrast medium distribution due to functional rather than to anatomical changes Acknowledgements The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [6]. Appendix A. Supplementary data Fig. 2. CT angiography showing inhomogeneous distribution of contrast medium in the aortic arch; transversal section.
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijcard.2008.12.157. References
Movies 2 and 3 online). Our colleagues suspected an acute Stanford Type A aortic dissection and took the patient to computed tomography which showed inhomogeneous distribution of contrast medium in the aortic arch and the descending aorta (Fig. 2; one additional figure is provided as Supplementary Figure 3 online). The patient was referred to our hospital for emergency thoracotomy which revealed an intact thoracic aorta and a competent tricuspid aortic valve. Six days after supportive treatment echocardiography revealed complete restoration of left ventricular function. This presentation reveals a case of mid-ventricular TakoTsubo cardiomyopathy with concomitant cardiogenic shock. The latter resulted in disturbed aortic blood flow pattern which was misinterpreted as aortic dissection. In patients with normal coronary arteries who present with elevated cardiac biomarkers and ECG changes, Tako-Tsubo cardio-
[1] Kurowski V, Kaiser A, von Hof K, et al. Apical and midventricular transient left ventricular dysfunction syndrome (Tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest 2007;132(3):809–16. [2] Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or Takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006;27(13):1523–9. [3] Banihashemi MR, Khan IA. Acute stress-induced cardiomyopathy: a brief observation. Int J Cardiol 2009;134:273–7. [4] Lyon AR, Rees PS, Prasad S, Poole-Wilson PA, Harding SE. Stress (Takotsubo) cardiomyopathy—a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med 2008;5(1):22–9. [5] Yoshida T, Hibino T, Fujimaki T, et al. The recurrence of Tako-tsubo cardiomyopathy complicated by cardiogenic shock: a case report. Int J Cardiol 2009;134:e132–4. [6] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.
Letter to the Editor
Tako-Tsubo cardiomyopathy mimicking acute aortic dissection: A case report Hendrik B. Sager ⁎, Heribert Schunkert, Volkhard Kurowski Medizinische Klinik II, Universität zu Lübeck, Ratzeburger Allee 160, D-23538 Lübeck, Germany Received 12 October 2008; accepted 14 December 2008 Available online 30 January 2009
Abstract Tako-Tsubo cardiomyopathy is characterized by a transient and reversible left ventricular dysfunction possibly due to a catecholaminemediated myocardial stunning. This form of cardiomyopathy is rarely associated with cardiogenic shock. Here we report on a patient with Tako-Tsubo cardiomyopathy induced low output failure in which blood flow disturbances in the thoracic aorta mimicked an acute type A aortic dissection. © 2008 Elsevier Ireland Ltd. All rights reserved. Keywords: Tako-Tsubo cardiomyopathy; Cardiogenic shock; Aortic dissection; Stress-induced cardiomyopathy; Transient apical ballooning syndrome
Transient left ventricular dysfunction, also termed TakoTsubo cardiomyopathy, has recently been recognized as a novel entity within the spectrum of acute coronary syndromes and affects approximately 1% of patients with a positive troponin [1]. It is especially seen in post-menopausal women after sudden emotional or physical stress [2,3]. Despite its increasing clinical awareness, the underlying pathophysiological mechanisms remain unclear. A few reports have suggested that the syndrome represents a form of catecholamine-induced acute myocardial stunning, with a predilection for the cardiac apex [4]. A 60-year-old woman presented in a nearby hospital with sudden onset of epigastric pain. Laboratory tests revealed elevated cardiac biomarkers (troponin T 1 µg/L, CK 390 U/L, CKMB 75 U/L). The ECG exhibited sinus rhythm with a right bundle branch block, Twave inversions in right precordial leads and horizontal ST segment depression located inferolaterally. The patient underwent cardiac catheterization revealing no stenosis or intraluminal thrombus. Left ventriculogram showed a markedly depressed ventricular function with mid-ventricular akinesia and preserved systolic contractility only of the apical and basal segments (movie is provided as Supplementary
Movie 1 online). During coronary angiography a prominent staining with contrast medium was observed at the inner curvature of the ascending aorta that was confirmed by aortography (Fig. 1, two movies are provided as Supplementary
⁎ Corresponding author. Tel.: +49 451 500 2421; fax: +49 451 500 2363. E-mail address: [email protected] (H.B. Sager).
Fig. 1. Withhold of contrast medium (arrows) in the ascending aorta after aortography.
0167-5273/$ - see front matter © 2008 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.ijcard.2008.12.157
H.B. Sager et al. / International Journal of Cardiology 145 (2010) e68–e69
69
myopathy should be considered. Tako-Tsubo cardiomyopathy can occasionally lead to cardiogenic shock [2,5] which may result in abnormal aortic contrast medium distribution due to functional rather than to anatomical changes Acknowledgements The authors of this manuscript have certified that they comply with the Principles of Ethical Publishing in the International Journal of Cardiology [6]. Appendix A. Supplementary data Fig. 2. CT angiography showing inhomogeneous distribution of contrast medium in the aortic arch; transversal section.
Supplementary data associated with this article can be found, in the online version, at doi:10.1016/j.ijcard.2008.12.157. References
Movies 2 and 3 online). Our colleagues suspected an acute Stanford Type A aortic dissection and took the patient to computed tomography which showed inhomogeneous distribution of contrast medium in the aortic arch and the descending aorta (Fig. 2; one additional figure is provided as Supplementary Figure 3 online). The patient was referred to our hospital for emergency thoracotomy which revealed an intact thoracic aorta and a competent tricuspid aortic valve. Six days after supportive treatment echocardiography revealed complete restoration of left ventricular function. This presentation reveals a case of mid-ventricular TakoTsubo cardiomyopathy with concomitant cardiogenic shock. The latter resulted in disturbed aortic blood flow pattern which was misinterpreted as aortic dissection. In patients with normal coronary arteries who present with elevated cardiac biomarkers and ECG changes, Tako-Tsubo cardio-
[1] Kurowski V, Kaiser A, von Hof K, et al. Apical and midventricular transient left ventricular dysfunction syndrome (Tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest 2007;132(3):809–16. [2] Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or Takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006;27(13):1523–9. [3] Banihashemi MR, Khan IA. Acute stress-induced cardiomyopathy: a brief observation. Int J Cardiol 2009;134:273–7. [4] Lyon AR, Rees PS, Prasad S, Poole-Wilson PA, Harding SE. Stress (Takotsubo) cardiomyopathy—a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med 2008;5(1):22–9. [5] Yoshida T, Hibino T, Fujimaki T, et al. The recurrence of Tako-tsubo cardiomyopathy complicated by cardiogenic shock: a case report. Int J Cardiol 2009;134:e132–4. [6] Coats AJ. Ethical authorship and publishing. Int J Cardiol 2009;131: 149–50.