Takotsubo cardiomyopathy secondary to electroconvulsive therapy in a young adult with Down syndrome regression disorder.

We report the case of an 18-year-old woman with Down syndrome (DS) who developed Takotsubo cardiomyopathy (TSC) immediately after the administration of electroconvulsive therapy (ECT), a treatment prescribed for Down syndrome regression disorder resistant to oral psychotropic drugs. TSC is a nonischemic cardiomyopathy related to psychological or physical stress, which has been described as a rare complication of ECT (Kinoshita et al., 2023, Journal of Electroconvulsive Therapy, 39, 185-192). The clinical description of the case is accompanied by a discussion of the peculiarities of the autonomic nervous system in DS.

Value of a short non-contrast CMR protocol in MINOCA.

OBJECTIVES: To evaluate the diagnostic performance of a short non-contrast CMR (ShtCMR) protocol relative to a matched standard comprehensive CMR (StdCMR) protocol in patients with myocardial infarction with non-obstructive coronary arteries (MINOCA). METHODS: This multicenter retrospective study included patients with a working diagnosis of MINOCA who underwent a StdCMR between January 2019 and December 2020. An expert and a non-expert reader performed a blinded reading with the ShtCMR (long-axis cine images, T2w-STIR, T1- and T2-mapping). A consensus reading of the StdCMR (reference standard) was performed at least 3 months after the ShtCMR reading session. Readers were asked to report the following: (1) diagnosis; (2) level of confidence in their diagnosis with the ShtCMR; (3) number of myocardial segments involved, and (4) functional parameters. RESULTS: A total of 179 patients were enrolled. The ShtCMR lasted 21 ± 9 min and the StdCMR 45 ± 11 min (p < 0.0001). ShtCMR allowed reaching the same diagnosis as StdCMR in 85% of patients when interpreted by expert readers (rising from 66% for poor confidence to 99% for good, p = 0.0001) and in 73% (p = 0.01) by non-expert ones (60% for poor vs 89% for good confidence, p = 0.0001). Overall, the ShtCMR overestimated the ejection fraction, underestimated cardiac volumes (p < 0.01), and underestimated the number of segments involved by pathology (p = 0.0008) when compared with the StdCMR. CONCLUSION: The ShtCMR was found to be a debatable alternative to the StdCMR in patients with MINOCA. Nevertheless, when an experienced reader reaches a good or very good diagnostic confidence using the ShtCMR, the reader may choose to stop the examination, reducing the length of the CMR without affecting the patient's diagnosis. CLINICAL RELEVANCE STATEMENT: A short non-contrast CMR protocol may be a viable alternative to standard protocols in selected CMR studies of patients with MINOCA, allowing for faster diagnosis while reducing time and resources and increasing the number of patients who can be scanned. KEY POINTS: • The ShtCMR lasted 21 ± 9 min and the StdCMR 45 ± 11 min (p < 0.0001). • In 57% of patients with MINOCA, the experienced reader considers that contrast medium is probably not necessary for diagnosis without affecting the patient's diagnosis (99% of agreement rate between ShtCMR and StdCMR).

Cushing's syndrome developing myasthenia gravis with takotsubo cardiomyopathy after adrenalectomy: a case report.

BACKGROUND: Several cases of autoimmune disease onset after treatment for Cushing's syndrome have been reported. CASE PRESENTATION: Herein, we report a case of myasthenia gravis crisis in a 51-year-old woman 2 months after adrenalectomy for adrenal Cushing's syndrome accompanied by takotsubo cardiomyopathy. The resolution of excessive endogenous cortisol after adrenalectomy may have triggered the onset of previously latent myasthenia gravis. CONCLUSIONS: Observing the similarities in symptoms between myasthenia gravis and adrenal crisis, which can sometimes be challenging to differentiate, is essential. Moreover, the presence of takotsubo cardiomyopathy as a non-motor manifestation of myasthenic crisis must be noted.

Histological and functional assessment of a Takotsubo cardiomyopathy model established by immobilization stress.

INTRODUCTION: Takotsubo cardiomyopathy (TTC), also known as stress-induced cardiomyopathy, resembles acute heart failure syndrome but lacks disease-specific diagnosis and treatment strategies. TTC accounts for approximately 5-6% of all suspected cases of acute coronary syndrome in women. At present, animal models of TTC are often created by large amounts of exogenous catecholamines such as isoproterenol. However, isoproterenol injection cannot fully simulate the onset of stress-induced cardiomyopathy in humans since stress is not an instantaneous event. METHODS: Rats were immobilized for 6 h per day for 1-14 days. To examine whether the TTC model was successful, echocardiography was employed; Elisa detected serum sympathetic activation markers; and the Open-Field test (OFT) was used to analyze behavioral changes in rats after stress. Western blot and histology were used to assess sympathetic remodeling, inflammation levels, and fibrosis; qRT-PCR was used to explore the levels of fibrosis and myocardial hypertrophy. The electrical stability of ventricular was determined by electrophysiological testing. RESULTS: The rats showed severe stress behavior and local sympathetic remodeling of the heart after only 1 day of stress. After 3 days of stress, the induction of ventricular tachyarrhythmia increased prominently. The highest incidence of TTC in rats was at 5 days of immobilization stress. The pathological left ventricular remodeling caused by immobilization (IMO) stress includes inflammatory infiltration, fibrosis, and myocardial hypertrophy. CONCLUSIONS: Our study confirms the hypothesis that IMO stress can mimic Takotsubo cardiomyopathy, and the various effects on the heart depending on the duration of IMO stress. We observed the highest incidence of TTC occurred after 5 days of stress. Furthermore, there is a gradual occurrence of electrical and structural remodeling as the stress duration prolongs.

A woman with schizophrenia who died due to Takotsubo cardiomyopathy occurring after electroconvulsive therapy.

BACKGROUND: Electroconvulsive therapy (ECT) is a safe treatment for treatment-resistant schizophrenia. However, it has some side effects, and Takotsubo cardiomyopathy is considered one of the minor complications. Several cases of patients developing Takotsubo cardiomyopathy during a course of ECT have been reported, but none have died. We present a case of post-ECT Takotsubo cardiomyopathy that became fatal. CASE PRESENTATION: We experienced a case of a 67-year-old woman who had delusions and catatonic symptoms due to schizophrenia but was resistant to several medications. Her symptoms improved by conducting ECT, but she had difficulty maintaining her improvement, which caused her to receive multiple courses of ECT. 3 weeks after her 6th course of ECT, the patient was diagnosed with Takotsubo cardiomyopathy and had a fatal outcome. CONCLUSION: Our patient had numerous cases of aspiration pneumonia and malnutrition before ECT was performed, which might have made this case fatal. In conclusion, appropriate supplementation of nutrition and reduction of physical stressors are important to avoid death from Takotsubo cardiomyopathy caused by ECT. Prescribing clozapine was a solution in the present case, but there are some difficulties, such as the restriction against prescribing this drug in Japan.

Postoperative electrocardiography changes: To worry or not to worry.

Abnormal postoperative electrocardiograms are not uncommon, oftentimes leading to further cardiac workup especially when the findings are new and not easily explainable. A forty-year-old woman, with a history of left breast cancer status post bilateral mastectomies and reconstructions, presented for robot-assisted low-anterior resection secondary to rectal cancer. Postoperative electrocardiogram showed poor R wave progression, biphasic T waves in V2-4, and possible anterior wall ischemia. Her electrocardiogram from 6 years ago was normal. No recent electrocardiogram was available for comparison. Initially, the abnormal postoperative electrocardiogram appeared worrisome. However, the patient was completely asymptomatic, and all vital signs were normal. Cardiac point-of-care ultrasound showed normal parasternal long and short axis views. The biphasic T waves in V2-4 were suggestive of Wellens syndrome, but the accompanying poor R wave progression was not consistent with the diagnostic criteria. The anesthesiologist then remembered the patient's history of the presence of a left breast implant and suspected it might have caused the changes on the electrocardiogram. A literature search did find one publication that shows approximately 45% of patients with breast implants present with electrocardiogram changes, including poor R wave progression and negative T waves. Therefore, no further cardiac workup was ordered for our patient. She was discharged home 3 days later. Breast implants and electrocardiogram changes are a lesser-known topic. Obtaining a pre-operative electrocardiogram should be considered in patients with previous breast implants, to serve as a baseline for comparison if the patient were to need another electrocardiogram in the future.

Clinical perspectives: Takotsubo cardiomyopathy.

Takotsubo syndrome is a condition characterised by temporary acute left ventricular dysfunction with regional wall abnormalities extending beyond a single coronary artery territory. Initially thought to be benign, this condition, which is challenging to distinguish from acute coronary syndrome, has substantial morbidity and mortality. The mechanism behind this condition remains elusive, but multiple theories have been proposed. Although beta blockers and angiotensin-converting enzyme inhibitors are used as treatments for left ventricular dysfunction, currently, there are no randomised controlled trials to support their use. In this paper, we review the latest evidence regarding aetiologies, pathophysiology, diagnostic criteria, prognosis, complications and management of Takotsubo syndrome.

Severe stress cardiomyopathy following spinal corrective surgery for scoliosis complicated with pectus excavatum: a case report.

BACKGROUND: Stress cardiomyopathy (SCM) is an acute heart failure syndrome characterized by transient, usually reversible left ventricular systolic dysfunction with normal or enhanced basal compensatory wall motion abnormalities involving the left ventricular anterior septum and apex, resulting in a "ballooning" appearance. However, it has rarely been reported in patients undergoing spinal surgery. CASE PRESENTATION: We report a case of severe stress cardiomyopathy in a scoliosis patient with pectus excavatum who underwent spinal corrective surgery. During the wake-up period, circulatory collapse occurred. After multidisciplinary consultation, the patient was diagnosed with stress cardiomyopathy. At last, she had a good prognosis after a series of treatments including ECMO. CONCLUSION: Stress cardiomyopathy is a reversible but uncommon condition. It can cause death if it is not diagnosed in time. Consequently, this report should improve the awareness of orthopedists and anesthesiologists for timely identification and management. For patients with potential risk factors, timely preoperative intervention should be performed to reduce the occurrence of stress cardiomyopathy.

Clinical characteristics of aneurysmal subarachnoid haemorrhage complicated by Takotsubo cardiomyopathy resulting in good neurological outcome.

BACKGROUND: Takotsubo cardiomyopathy (TC) is a well-known complication of subarachnoid haemorrhage (SAH), often accompanied by neurogenic myocardial dysfunction. Although TC has been reported to be associated with higher morbidity and mortality among patients with aneurysmal SAH (aSAH), some patients have been reported to recover, the profiles and follow-up outcomes of these survivors remain unclear. MATERIALS AND METHODS: To characterize the profiles of patients with aSAH complicated by TC who experienced favourable outcomes using long-term follow-up data, a consecutive series of patients with aSAH were enrolled and TC diagnosis was based on the revised version of the Mayo Clinic criteria. Clinical outcomes were assessed at 6 months according to modified Rankin Scale scores. RESULTS: Among 165 consecutive patients with aSAH, 15 cases were complicated by TC, corresponding to an occurrence rate of 9.0%. Five patients with aSAH complicated by TC (33.3%) experienced a favourable outcome, and the mean value of systolic blood pressure on arrival was significantly lower than in those who experienced an unfavourable outcome (p = 0.032). CONCLUSION: According to analysis, it is possible cardiac dysfunction with decreased cerebral perfusion pressure and catecholamine toxicity transiently worsens conscious disturbance in aSAH complicated by TC. Therefore, it is important to carefully screen patients with aSAH to identify those complicated by TC, and for close collaboration of the multidisciplinary team to design appropriate treatment strategies.

Cardiac Angiosarcoma in the Right Atrium Treated by Surgical Resection.

We present the case of a 49-year-old female of Caucasian European descent with chest tightness, fatigue, and palpitations, ultimately diagnosed with primary intracardiac angiosarcoma. Initial echocardiography revealed a significant mass within the right atrium, infiltrating the free wall. Surgical intervention included tumor excision and partial resection of the superior vena cava. Histopathological examination confirmed a high-grade angiosarcoma. Postoperative imaging identified a recurrent mass in the right atrium, suggestive of thrombus, alongside Takotsubo cardiomyopathy. Considering the elevated surgical risks and the presence of cardiomyopathy, management included anticoagulation therapy with Warfarin and adjuvant chemotherapy with Paclitaxel. Follow-up cardiac magnetic resonance imaging demonstrated a recurrent angiosarcoma with superimposed thrombus. This case presents the complex diagnostic and therapeutic landscape of angiosarcoma, highlighting the critical importance of early surgical intervention, advanced imaging techniques, and vigilant postoperative monitoring.

Characteristics and outcomes of patients with cardiac conditions requiring emergency medical retrieval from the Great Barrier Reef, Australia.

INTRODUCTION: There is limited published data on the burden of cardiac disease among patients requiring emergency medical evacuation from the Great Barrier Reef, a popular tourist destination in Far North Queensland, Australia. The aim of this study was to examine the characteristics and outcomes of patients with cardiac conditions who were retrieved from the northern Great Barrier Reef to Cairns Hospital. METHODS: This observational study was a planned substudy of a broader analysis of medical retrievals from the Cairns/Cooktown section of the Great Barrier Reef. It included all patients retrieved to Cairns Hospital between July 2016 and January 2020 who were assigned a cardiac diagnosis during their hospital stay. Data were collected about electrocardiograph, cardiac troponin blood test and invasive coronary angiography results as well as final hospital diagnosis. RESULTS: During the study period, 120 patients were retrieved from the Great Barrier Reef to Cairns Hospital, of which 46 (38%) were subsequently diagnosed with a primary cardiac condition(s) or other disease process with clinically significant cardiac involvement. The most common diagnoses were type 2 myocardial infarction (20; 16.7% of all retrievals), primary cardiac arrhythmia (14; 12.5%) and acute coronary syndrome (5; 4.2%). An elevated troponin was recorded in 30% of all retrievals and in 78% of those with a cardiac diagnosis. A total of 14 (30.4%) of patients with a cardiac diagnosis died during their hospital admission. Invasive coronary angiography was performed in 18 cases, of which six patients had obstructive coronary artery disease. Four patients required percutaneous coronary intervention. CONCLUSION: A high proportion of patients retrieved to Cairns Hospital from the Great Barrier Reef were diagnosed with a primary cardiac condition. This data may assist tourism operators, retrieval organisations and health services to plan for, and respond to, cardiac events among visitors to the reef.

Fast resolution of mild midvetricular takotsubo syndrome triggered by blunt chest trauma: case study.

Blunt chest trauma (BCT) may rarely trigger stress-induced takotsubo syndrome (TTS) which requires dif f erential diagnosis with myocardial contusion and BCT-induced myocardial infarction. So far reported cases have been presented as apical ballooning or inverted (reverse) TTS forms but not as a midventricular variant. The authors described a case of a 53-year-old female admitted to Intensive Care Unit after motor vehicle accident with BCT and airbag deployment during car roll over. For some time after the accident, she was trapped in a car with her head bent to the chest. After being pulled out from the car, she had impaired consciousness and therefore was intubated by the rescue team. Trauma computed tomography scan did not reveal any injuries. However, ECG showed ST-segment depression in II, III, aVF, V4-6, and discrete ST-segment elevation in aVR. Troponin I and NTpro-BNP increased to 2062 ng/l and 6413 pg/ml, respectively. Echocardiography revealed mild midventricular dysfunction of the left ventricle with ejection fraction (EF) and global longitudinal strain (GLS) reduced to 45% and -17.6%, respectively. On day two, the patient's general condition improved and stabilized, so she was extubated. Normalization of ECG, EF and GLS (but not regional LS) was observed on day three. She was discharged home on day fi ve. Post-hospital examinations documented that segmental longitudinal strain remained abnormal for up to 4 weeks. The authors conclude that fast ECG and echocardiographic evolution may result in underestimation of the posttraumatic TTS diagnosis, especially if it takes atypical form and its course is mild. Longitudinal strain evaluation can be helpful in cardiac monitoring of trauma patients.

Takotsubo Syndrome: Pathophysiology, Emerging Concepts, and Clinical Implications.

Takotsubo syndrome is a condition characterized by acute transient left ventricular systolic dysfunction, which at presentation can be challenging to distinguish from acute myocardial infarction. Although previously thought to be a benign, self-limiting condition, recent studies have confirmed that patients with takotsubo syndrome have persistent subtle ongoing cardiac dysfunction, and many continue to have limiting symptoms despite restoration of left ventricular ejection fraction. Moreover, these patients have a substantial burden of morbidity and mortality, as well, with high rates of subsequent major adverse cardiovascular events that approach those of patients with acute coronary syndrome. The mechanisms behind this condition remain elusive. Despite substantial research, the medical community continues to have an incomplete understanding of its underlying pathogenesis and pathophysiology. Catecholamine-induced myocardial injury is the most established and well-known theory, but this does not explain all the clinical features and presentations of the condition, and numerous other pathways and abnormalities are emerging. Because of the poor understanding of its underlying pathophysiology, there is a lack of evidence-based interventions to treat the acute episode, to avoid recurrences, and to prevent major adverse cardiovascular events. This highlights the need for further research to gain a better understanding of the underlying pathophysiology to inform appropriate randomized controlled trials of interventions targeting the causative pathways. Only then can evidence-based management strategies be established to improve clinical outcomes of this potentially lethal condition.

Manganese-Enhanced Magnetic Resonance Imaging in Takotsubo Syndrome.

BACKGROUND: Takotsubo syndrome is an acute cardiac emergency characterized by transient left ventricular systolic dysfunction typically following a stressful event. Despite its rapidly rising incidence, its pathophysiology remains poorly understood. Takotsubo syndrome may pass unrecognized, especially if timely diagnostic imaging is not performed. Defective myocardial calcium homeostasis is a central cause of contractile dysfunction and has not been explored in takotsubo syndrome. We aimed to investigate myocardial calcium handling using manganese-enhanced magnetic resonance imaging during the acute and recovery phases of takotsubo syndrome. METHODS: Twenty patients with takotsubo syndrome (63±12 years of age; 90% female) and 20 volunteers matched on age, sex, and cardiovascular risk factors (59±11 years of age; 70% female) were recruited from the Edinburgh Heart Centre between March 2020 and October 2021. Patients underwent gadolinium and manganese-enhanced magnetic resonance imaging during index hospitalization with repeat manganese-enhanced magnetic resonance imaging performed after at least 3 months. RESULTS: Compared with matched control volunteers, patients had a reduced left ventricular ejection fraction (51±11 versus 67±8%; P<0.001), increased left ventricular mass (86±11 versus 57±14 g/m2; P<0.001), and, in affected myocardial segments, elevated native T1 (1358±49 versus 1211±28 ms; P<0.001) and T2 (60±7 versus 38±3 ms; P<0.0001) values at their index presentation. During manganese-enhanced imaging, kinetic modeling demonstrated a substantial reduction in myocardial manganese uptake (5.1±0.5 versus 8.2±1.1 mL/[100 g of tissue ·min], respectively; P<0.0001), consistent with markedly abnormal myocardial calcium handling. After recovery, left ejection fraction, left ventricular mass, and T2 values were comparable with those of matched control volunteers. Despite this, native and postmanganese T1 and myocardial manganese uptake remained abnormal compared with matched control volunteers (6.6±0.5 versus 8.2±1.1 mL/[100 g of tissue ·min]; P<0.0001). CONCLUSIONS: In patients with takotsubo syndrome, there is a profound perturbation of myocardial manganese uptake, which is most marked in the acute phase but persists for at least 3 months despite apparent restoration of normal left ventricular ejection fraction and resolution of myocardial edema, suggesting abnormal myocardial calcium handling may be implicated in the pathophysiology of takotsubo syndrome. Manganese-enhanced magnetic resonance imaging has major potential to assist in the diagnosis, characterization, and risk stratification of patients with takotsubo syndrome. REGISTRATION: URL: https://www. CLINICALTRIALS: gov; Unique identifier: NCT04623788.

Pregnancy-associated takotsubo cardiomyopathy hospitalizations in the United States.

Takotsubo cardiomyopathy (TCM) is most common not only in postmenopausal women aged ≥50 yr but also in pregnant individuals. However, there are no national estimates on the prevalence, timing of occurrence, correlates, and outcomes of pregnancy-associated TCM. Using the Nationwide Inpatient Sample (NIS: 2016-2020), we describe rates of pregnancy-associated TCM hospitalizations among 13- to 49-yr-old pregnant individuals in the United States by selected demographic, behavioral, hospital, and clinical characteristics. Joinpoint regression was used to describe the annual average percent change of pregnancy-associated TCM hospitalizations. Survey logistic regression was used to measure the association of pregnancy-associated TCM hospitalizations with maternal outcomes. Of the 19,754,535 pregnancy-associated hospitalizations, 590 were TCM associated. The overall trend in pregnancy-associated TCM hospitalizations remained stable during the study period. The majority of TCM occurred during the postpartum, followed by antepartum and delivery-associated hospitalizations. When compared with pregnancy hospitalizations without TCM, those with TCM were more likely to be over the age of 35 yr and use tobacco and opioids. Comorbidities during TCM-associated pregnancy hospitalizations included heart failure, coronary artery disease, hemorrhagic stroke, and hypertension. After controlling for potential confounders, the odds of pregnancy-associated TCM hospitalizations were 98.7 times [adjusted odds ratio (aOR) = 98.66, 95% confidence interval (CI) 31.23-311.64] and 14.7 times (aOR = 14.75, 95% CI 9.99-21.76) higher for experiencing in-hospital mortality and a prolonged hospital stay, respectively, than those without TCM. Although rare, pregnancy-associated TCM hospitalization is more likely to occur during the postpartum period and is associated with in-hospital mortality and prolonged hospital stay.NEW & NOTEWORTHY Although rare, pregnancy-associated takotsubo cardiomyopathy hospitalizations are more likely to occur during the postpartum period and are associated with in-hospital mortality and prolonged hospital stay.

Role of miR-204 in segmental cardiac effects of phenylephrine and pressure overload.

Cardiotoxicity caused by adrenergic receptor agonists overdosing or stress-induced catecholamine release promotes cardiomyopathy, resembling Takotsubo cardiomyopathy (TC). TC is characterized by transient regional systolic dysfunction of the left ventricle. The animal models of TC and modalities for assessing regional wall motion abnormalities in animal models are lacking. We previously reported the protective role of a small noncoding microRNA-204-5p (miR-204) in cardiomyopathies, but its role in TC remains unknown. Here we compared the impact of miR-204 absence on phenylephrine (PE)-induced and transaortic constriction (TAC)-induced changes in cardiac muscle motion in the posterior and anterior apical, mid, and basal segments of the left ventricle using 2-dimensional speckle-tracking echocardiography (2-STE). Wildtype and miR-204-/- mice were subjected to cardiac stress in the form of PE for four weeks or TAC-induced pressure overload for five weeks. PE treatment increased longitudinal and radial motion in the apex of the left ventricle and shortened the peak motion time of all left ventricle segments. The TAC led to decreased longitudinal and radial motion in the left ventricle segments, and there was no difference in the peak motion time. Compared to wildtype mice, PE-induced peak cardiac muscle motion time in the anterior base of the left ventricle was significantly earlier in the miR-204-/- mice. There was no difference in TAC-induced peak cardiac muscle motion time between wildtype and miR-204-/- mice. Our findings demonstrate that PE and TAC induce regional wall motion abnormalities that 2-STE can detect. It also highlights the role of miR-204 in regulating cardiac muscle motion during catecholamine-induced cardiotoxicity.

Cardiac MRI in patients with COVID-19 infection.

OBJECTIVE: COVID-19 infection is a systemic disease with various cardiovascular symptoms and complications. Cardiac MRI with late gadolinium enhancement is the modality of choice for the assessment of myocardial involvement. T1 and T2 mapping can increase diagnostic accuracy and improve further management. Our study aimed to evaluate the different aspects of myocardial damage in cases of COVID-19 infection using cardiac MRI. METHODS: This descriptive retrospective study included 86 cases, with a history of COVID-19 infection confirmed by positive RT-PCR, who met the inclusion criteria. Patients had progressive chest pain or dyspnoea with a suspected underlying cardiac cause, either by an abnormal electrocardiogram or elevated troponin levels. Cardiac MRI was performed with late contrast-enhanced (LGE) imaging, followed by T1 and T2 mapping. RESULTS: Twenty-four patients have elevated hsTnT with a median hsTnT value of 133 ng/L (IQR: 102 to 159 ng/L); normal value < 14 ng/L. Other sixty-two patients showed elevated hsTnI with a median hsTnI value of 1637 ng/L (IQR: 1340 to 2540 ng/L); normal value < 40 ng/L. CMR showed 52 patients with acute myocarditis, 23 with Takotsubo cardiomyopathy, and 11 with myocardial infarction. Invasive coronary angiography was performed only in selected patients. CONCLUSION: Different COVID-19-related cardiac injuries may cause similar clinical symptoms. Cardiac MRI is the modality of choice to differentiate between the different types of myocardial injury such as Takotsubo cardiomyopathy and infection-related cardiomyopathy or even acute coronary syndrome secondary to vasculitis or oxygen-demand mismatch. KEY POINTS: • It is essential to detect early COVID-related cardiac injury using different cardiac biomarkers and cardiac imaging, as it has a significant impact on patient management and outcome. • Cardiac MRI is the modality of choice to differentiate between the different aspects of COVID-related myocardial injury.

Pediatric Takotsubo cardiomyopathy resulting from clonidine overdose.

Takotsubo cardiomyopathy is a syndrome characterized by localized apical dysfunction of the left ventricle. It is rarely seen in pediatric patients, but can carry significant morbidity and mortality. While most commonly associated with psychosocial stressors or physical exertion, a growing number of cases are being attributed to medications. We describe a case of a six-month-old male diagnosed with Takotsubo cardiomyopathy in the setting of an accidental clonidine overdose. The patient presented with altered mental status and hypertension. In the course of his broad workup, cardiac dysfunction was indicated by bedside ultrasound in the Emergency Department. The classic apical dyskinesis was seen on a follow-up, cardiology-based echocardiogram. The patient responded to high-dose naloxone and only briefly required an epinephrine infusion. His symptoms resolved in a few days and serial echocardiograms showed a return to normal LV function. Rates of pediatric clonidine overdoses are increasing in the setting of changing prescribing practices. Our case illustrates some key features of the clinical presentation, as well as demonstrates a rare sequelae to this common toxic exposure. To our knowledge, this is the first reported pediatric case of Takotsubo cardiomyopathy secondary to a clonidine overdose.

Can longitudinal strain analysis differentiate between Takotsubo syndrome and acute coronary syndrome?

BACKGROUND: Takotsubo syndrome (TTS) is characterized by transient abnormalities of myocardial contractility. Noninvasive tests are currently being sought to differentiate TTS from acute coronary syndrome (ACS). THE AIM OF THE STUDY: To evaluate the prevalence of TTS and echocardiographic parameters to distinguish apical TTS from acute anterior wall infarction. MATERIAL AND METHODS: The medical records of patients with suspected TTS, hospitalized in the Department of Cardiology (TTS group n = 18) were analyzed. The control group included patients with STEMI of the left ventricle anterior wall and anterior and lateral wall (STEMI group n = 17). Standard transthoracic echocardiography (TTE) was supplemented with segmental longitudinal strain (LS) assessment with the use of acoustic marker tracking. RESULTS: A statistically significant difference was observed in the second cardiac troponine I (CTNI) measurement (TTS: 3241.2 ng/L vs. STEMI: 12032.6 ng/L; p < 0.05). A significant difference in left and right ventricular size was observed on TTE. Left ventricular end-diastolic and end-systolic volumes were considerably smaller in TTS group; (86.1 vs. 104 ml and 48.1 vs. 74.1 ml, respectively). LS were significantly higher (in absolute values) in patients with TTS than in those with STEMI in the apical and middle lateral segments, LS in the apical four-chamber view (apSept -14.9 vs. -8.9; apLat -14.8 vs. -6.84; midLat -13.26 vs. -9.11). CONCLUSIONS: Patients with TTS are characterized by a different LS pattern in the apical segments of the left ventricle compared to patients with STEMI. TTE examination with LS remains insufficient to distinguish TTS from ACS at the early stage of diagnosis.

Takotsubo syndrome: more frequent in women, more dangerous in men.

Takotsubo syndrome (TTS) is an acute myocardial disease characterized by reversible left ventricular dysfunction, in the absence of obstructive coronary artery disease, caused by adrenergic overactivity and associated with non-negligible morbidity and mortality. Takotsubo syndrome, by far more frequent in women, who account for 9 out of 10 cases, is generally triggered by intense psychoemotional stress. In men, TTS has different, though not yet fully defined, characteristics and clinical course. In fact, men have a higher prevalence of a physical trigger and comorbidities, such as bronchopulmonary or cerebral pathologies, diabetes mellitus, and malignant neoplasms. The hospital course is burdened by a higher rate of cardiogenic shock and mortality. The long-term prognosis is also less favourable in men. Takotsubo syndrome in men characterizes a higher-risk phenotype, which requires close monitoring during hospitalization and careful surveillance during follow-up.