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Transient left ventricular apical ballooning during dobutamine myocardial perfusion imaging
International Journal of Cardiology 124 (2008) 378 – 380 www.elsevier.com/locate/ijcard
Letter to the Editor
Transient left ventricular apical ballooning during dobutamine myocardial perfusion imaging Ashwani Kumar ⁎, Leigh Ann Jenkins, Alejandro Perez-Verdia, Chanwit Roongsritong Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, Texas 79430, United States Received 7 September 2006; received in revised form 26 November 2006; accepted 27 November 2006 Available online 28 March 2007
Abstract The transient left ventricular apical ballooning is characterized by wall motion abnormalities involving the apex in the absence of obstructive coronary disease. It is precipitated by acute emotional or physical stress and is most often reported in post-menopausal women. We report a case of transient left ventricular “apical ballooning” without significant coronary artery disease precipitated by high dose dobutamine infusion during pharmacological stress myocardial perfusion imaging. The unique feature of our case was precipitation by chemical stress rather than emotional/physical stress. Published by Elsevier Ireland Ltd. Keywords: Transient left ventricular apical ballooning; Dobutamine stress test; Chemical stress
1. Introduction The transient left ventricular (LV) apical ballooning is a recently described acute cardiac syndrome. It is characterized by a transient dilation and akinesis or dyskinesis of the LV apex and mid-ventricular segments in the absence of coronary artery stenosis [1]. It was first reported in the Japanese population and also known as tako-tsubo cardiomyopathy after a short-neck, round-flask Japanese fishing pot used for trapping octopus [1,2]. Its actual incidence is currently unknown. In a recent report, this condition accounted for approximately 2.2% of patients presenting with acute chest pain and ST segment elevation [3]. The majority of reported cases are post-menopausal females who develop the signs and symptoms during an episode of acute and/or severe emotional or physical stress [2]. However, the pathophysiology of this syndrome remains incompletely understood. Dobutamine is a common pharmacological agent used for noninvasive evaluation of coronary artery disease. ST segment elevation in the EKG leads without Q waves during
⁎ Corresponding author. Tel.: +1 806 743 3155; fax: +1 806 743 3148. E-mail address: [email protected] (A. Kumar). 0167-5273/$ - see front matter. Published by Elsevier Ireland Ltd. doi:10.1016/j.ijcard.2006.11.248
dobutamine stress test is typically considered as a reliable marker for severe myocardial ischemia due to obstructive coronary lesion. We report a case of ST segment elevation during dobutamine myocardial perfusion imaging secondary to transient LV apical ballooning. 2. Case report A 66 year old female underwent a dobutamine myocardial perfusion imaging as a part of her preoperative evaluation for cholecystectomy. Her past medical history was significant for hypertension, depression and tobacco abuse. She had no prior history of myocardial infarction or angina. She also had no previous head trauma or recent flu-like symptoms. During the high dose infusion of dobutamine, she developed severe retrosternal chest pain and 2 to 3 mm ST segment elevation in inferior leads and V4–5. Her chest pain was relieved with sublingual nitroglycerin but the ST elevation persisted. Cardiac catheterization was urgently performed and revealed angiographically normal epicardial coronary arteries. The left ventriculogram demonstrated an akinetic and dilated LVapex with hypercontractility of the mid-ventricular and basal segments (Fig. 1). Troponin-T level six hours later increased to 0.73 ng/ml (normal range b0 .01 ng /ml).
A. Kumar et al. / International Journal of Cardiology 124 (2008) 378–380
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2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture. 3. New electrocardiographic abnormalities (either ST-segment elevation or T-wave inversion). 4. Absence of: Recent significant head trauma Intracranial bleeding Pheochromocytoma Myocarditis Hypertrophic cardiomyopathy.
Fig. 1. Left ventriculogram showing typical apical ballooning during systole (akinesis of apex with normal mid and basal-segments contractility).
A transthoracic echocardiogram (TTE) performed immediately after the cardiac catheterization confirmed the findings of akinetic and dilated LV apex (Fig. 2 A, B). Additionally, there was no echocardiographic evidence of hypertrophic cardiomyopathy. The rest of her hospital course was uneventful. She was discharged from the hospital the following day. A week later, a repeat TTE revealed a normal left ventricle size and function without evidence of regional wall motion abnormalities (Fig. 2 C, D). 3. Discussion Transient LV apical ballooning syndrome is a relatively new entity. Thus, its diagnostic criteria have not been completely standardized. In a recent systematic review, Bybee et al. [2] proposed that all four of the following criteria must be present for clinical diagnosis of transient LV apical ballooning syndrome: 1. Transient akinesis or dyskinesis of the LV apical and mid ventricular segment with regional wall motion abnormalities extending beyond a single epicardial vascular distribution.
ST segment elevation and regional wall motion abnormalities have been reported in 14% of patients with symptomatic vasospastic angina and normal coronary arteries undergoing dobutamine stress echocardiography [4]. Our patient, however, did not have clinical features of vasospatic angina and met all of the above criteria proposed by Bybee et al. for transient LV apical ballooning syndrome. Neurogenically-mediated myocardial stunning and myocardial dysfunction mediated by catecholamines has been implicated in the pathophysiology of this syndrome. Recently, Wittstein et al. [5] demonstrated that plasma catecholamine (epinephrine, norepinephrine and dopamine) levels at presentation are markedly higher among patients with stressinduced transient cardiomyopathy than among patients with Killip class III myocardial infarction. More recently, Marli E et al. [6] proposed that LV apical ballooning occurs as a result of regional myocardial dysfunction characterized by localized enhancement of mid-ventricular septal thickening. They believed that this abnormal myocardial functional architecture in the presence of elevated catecholamines or dehydration can lead to transient severe mid-cavitory obstruction and stunning of the LV apex due to markedly increased wall stress. More importantly, this abnormality can be reproduced by dobutamine infusion. Takizawa et al. [7] reported a case having “takatsubo”-like left ventricular asynergy with pheochromocytoma, whose cardiac abnormalities improved after adrenalectomy. This case further supports the pathogenetic role of catecholamines in this syndrome. Therefore, we believe that our patient developed transient LV apical ballooning syndrome during dobutamine stress myocardial perfusion imaging. In her case, high dose of dobutamine used during pharmacological stress test along with some degree of dehydration from fasting and emotional stress related to testing and anticipated surgery likely contributed to the development of transient LV dysfunction. More importantly, our case illustrated that transient LV apical ballooning syndrome should be considered in the differential diagnoses of ST segment elevation during pharmacological stress testing utilizing dobutamine, particularly in postmenopausal women. 4. Conclusion ST segment elevation during dobutamine infusion may occur as a result of a recently described syndrome called
380
A. Kumar et al. / International Journal of Cardiology 124 (2008) 378–380
Fig. 2. Echocardiogram: Apical four chamber views. A and B Initial echocardiogram showing akinetic apex with normal mid and basal-segments contractility. C and D Echocardiogram done one week later reveals normally contracting apical segments.
transient LV apical ballooning. Adequate hydration and tranquil environment should be provided during the test to minimize its occurrence. References [1] Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina pectorismyocardial infarction investigations in Japan. J Am Coll Cardiol 2001;38: 11–82. [2] Bybee KA, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: the syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004;141:858–65. [3] Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with
[4]
[5]
[6]
[7]
transient left ventricular apical ballooning syndrome. Am J Cardiol 2004;94:343–6. Kawano H, Fujii H, Motoyama T, et al. Myocardial ischemia due to coronary artery spasm during dobutamine stress echocardiography. Am J Cardiol 2000;85:26–30. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48. Merli E, Sutcliffe S, Gori M, Sutherland G. Tako-Tsubo cardiomyopathy: new insights into the possible underlying pathophysiology. Eur J Echocardiogr 2006;7:53–61. Takizawa M, Kobayakawa N, Uozumi H, et al. A case of transient left ventricular ballooning with pheochromocytoma, supporting pathogenetic role of catecholamines in stress-induced cardiomyopathy or takotsubo cardiomyopathy. Int J Cardiol 2007;114:e15–7.
Letter to the Editor
Transient left ventricular apical ballooning during dobutamine myocardial perfusion imaging Ashwani Kumar ⁎, Leigh Ann Jenkins, Alejandro Perez-Verdia, Chanwit Roongsritong Division of Cardiology, Department of Internal Medicine, Texas Tech University Health Sciences Center, 3601 4th Street, Lubbock, Texas 79430, United States Received 7 September 2006; received in revised form 26 November 2006; accepted 27 November 2006 Available online 28 March 2007
Abstract The transient left ventricular apical ballooning is characterized by wall motion abnormalities involving the apex in the absence of obstructive coronary disease. It is precipitated by acute emotional or physical stress and is most often reported in post-menopausal women. We report a case of transient left ventricular “apical ballooning” without significant coronary artery disease precipitated by high dose dobutamine infusion during pharmacological stress myocardial perfusion imaging. The unique feature of our case was precipitation by chemical stress rather than emotional/physical stress. Published by Elsevier Ireland Ltd. Keywords: Transient left ventricular apical ballooning; Dobutamine stress test; Chemical stress
1. Introduction The transient left ventricular (LV) apical ballooning is a recently described acute cardiac syndrome. It is characterized by a transient dilation and akinesis or dyskinesis of the LV apex and mid-ventricular segments in the absence of coronary artery stenosis [1]. It was first reported in the Japanese population and also known as tako-tsubo cardiomyopathy after a short-neck, round-flask Japanese fishing pot used for trapping octopus [1,2]. Its actual incidence is currently unknown. In a recent report, this condition accounted for approximately 2.2% of patients presenting with acute chest pain and ST segment elevation [3]. The majority of reported cases are post-menopausal females who develop the signs and symptoms during an episode of acute and/or severe emotional or physical stress [2]. However, the pathophysiology of this syndrome remains incompletely understood. Dobutamine is a common pharmacological agent used for noninvasive evaluation of coronary artery disease. ST segment elevation in the EKG leads without Q waves during
⁎ Corresponding author. Tel.: +1 806 743 3155; fax: +1 806 743 3148. E-mail address: [email protected] (A. Kumar). 0167-5273/$ - see front matter. Published by Elsevier Ireland Ltd. doi:10.1016/j.ijcard.2006.11.248
dobutamine stress test is typically considered as a reliable marker for severe myocardial ischemia due to obstructive coronary lesion. We report a case of ST segment elevation during dobutamine myocardial perfusion imaging secondary to transient LV apical ballooning. 2. Case report A 66 year old female underwent a dobutamine myocardial perfusion imaging as a part of her preoperative evaluation for cholecystectomy. Her past medical history was significant for hypertension, depression and tobacco abuse. She had no prior history of myocardial infarction or angina. She also had no previous head trauma or recent flu-like symptoms. During the high dose infusion of dobutamine, she developed severe retrosternal chest pain and 2 to 3 mm ST segment elevation in inferior leads and V4–5. Her chest pain was relieved with sublingual nitroglycerin but the ST elevation persisted. Cardiac catheterization was urgently performed and revealed angiographically normal epicardial coronary arteries. The left ventriculogram demonstrated an akinetic and dilated LVapex with hypercontractility of the mid-ventricular and basal segments (Fig. 1). Troponin-T level six hours later increased to 0.73 ng/ml (normal range b0 .01 ng /ml).
A. Kumar et al. / International Journal of Cardiology 124 (2008) 378–380
379
2. Absence of obstructive coronary disease or angiographic evidence of acute plaque rupture. 3. New electrocardiographic abnormalities (either ST-segment elevation or T-wave inversion). 4. Absence of: Recent significant head trauma Intracranial bleeding Pheochromocytoma Myocarditis Hypertrophic cardiomyopathy.
Fig. 1. Left ventriculogram showing typical apical ballooning during systole (akinesis of apex with normal mid and basal-segments contractility).
A transthoracic echocardiogram (TTE) performed immediately after the cardiac catheterization confirmed the findings of akinetic and dilated LV apex (Fig. 2 A, B). Additionally, there was no echocardiographic evidence of hypertrophic cardiomyopathy. The rest of her hospital course was uneventful. She was discharged from the hospital the following day. A week later, a repeat TTE revealed a normal left ventricle size and function without evidence of regional wall motion abnormalities (Fig. 2 C, D). 3. Discussion Transient LV apical ballooning syndrome is a relatively new entity. Thus, its diagnostic criteria have not been completely standardized. In a recent systematic review, Bybee et al. [2] proposed that all four of the following criteria must be present for clinical diagnosis of transient LV apical ballooning syndrome: 1. Transient akinesis or dyskinesis of the LV apical and mid ventricular segment with regional wall motion abnormalities extending beyond a single epicardial vascular distribution.
ST segment elevation and regional wall motion abnormalities have been reported in 14% of patients with symptomatic vasospastic angina and normal coronary arteries undergoing dobutamine stress echocardiography [4]. Our patient, however, did not have clinical features of vasospatic angina and met all of the above criteria proposed by Bybee et al. for transient LV apical ballooning syndrome. Neurogenically-mediated myocardial stunning and myocardial dysfunction mediated by catecholamines has been implicated in the pathophysiology of this syndrome. Recently, Wittstein et al. [5] demonstrated that plasma catecholamine (epinephrine, norepinephrine and dopamine) levels at presentation are markedly higher among patients with stressinduced transient cardiomyopathy than among patients with Killip class III myocardial infarction. More recently, Marli E et al. [6] proposed that LV apical ballooning occurs as a result of regional myocardial dysfunction characterized by localized enhancement of mid-ventricular septal thickening. They believed that this abnormal myocardial functional architecture in the presence of elevated catecholamines or dehydration can lead to transient severe mid-cavitory obstruction and stunning of the LV apex due to markedly increased wall stress. More importantly, this abnormality can be reproduced by dobutamine infusion. Takizawa et al. [7] reported a case having “takatsubo”-like left ventricular asynergy with pheochromocytoma, whose cardiac abnormalities improved after adrenalectomy. This case further supports the pathogenetic role of catecholamines in this syndrome. Therefore, we believe that our patient developed transient LV apical ballooning syndrome during dobutamine stress myocardial perfusion imaging. In her case, high dose of dobutamine used during pharmacological stress test along with some degree of dehydration from fasting and emotional stress related to testing and anticipated surgery likely contributed to the development of transient LV dysfunction. More importantly, our case illustrated that transient LV apical ballooning syndrome should be considered in the differential diagnoses of ST segment elevation during pharmacological stress testing utilizing dobutamine, particularly in postmenopausal women. 4. Conclusion ST segment elevation during dobutamine infusion may occur as a result of a recently described syndrome called
380
A. Kumar et al. / International Journal of Cardiology 124 (2008) 378–380
Fig. 2. Echocardiogram: Apical four chamber views. A and B Initial echocardiogram showing akinetic apex with normal mid and basal-segments contractility. C and D Echocardiogram done one week later reveals normally contracting apical segments.
transient LV apical ballooning. Adequate hydration and tranquil environment should be provided during the test to minimize its occurrence. References [1] Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina pectorismyocardial infarction investigations in Japan. J Am Coll Cardiol 2001;38: 11–82. [2] Bybee KA, Kara T, Prasad A, et al. Systematic review: transient left ventricular apical ballooning: the syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med 2004;141:858–65. [3] Bybee KA, Prasad A, Barsness GW, et al. Clinical characteristics and thrombolysis in myocardial infarction frame counts in women with
[4]
[5]
[6]
[7]
transient left ventricular apical ballooning syndrome. Am J Cardiol 2004;94:343–6. Kawano H, Fujii H, Motoyama T, et al. Myocardial ischemia due to coronary artery spasm during dobutamine stress echocardiography. Am J Cardiol 2000;85:26–30. Wittstein IS, Thiemann DR, Lima JA, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med 2005;352:539–48. Merli E, Sutcliffe S, Gori M, Sutherland G. Tako-Tsubo cardiomyopathy: new insights into the possible underlying pathophysiology. Eur J Echocardiogr 2006;7:53–61. Takizawa M, Kobayakawa N, Uozumi H, et al. A case of transient left ventricular ballooning with pheochromocytoma, supporting pathogenetic role of catecholamines in stress-induced cardiomyopathy or takotsubo cardiomyopathy. Int J Cardiol 2007;114:e15–7.