Pediatric takotsubo cardiomyopathy: A review and insights from a National Multicentric Registry.

Takotsubo syndrome (TTS) in the pediatric population is an infrequent but relevant cause of morbidity and mortality, with limited studies addressing its clinical course and prognosis. We aimed to analyze the clinical features and prognosis of pediatric TTS in a nation-wide multicenter registry and considering the published literature. We included a total of 54 patients from 4 different hospitals in Spain, as well as pediatric TTS patients from the published literature. Comparisons between groups were performed in order to assess for statistically and clinically relevant prognostic differences between pediatric and adult population features. Patients with pediatric TTS are more commonly male and exhibit a higher prevalence of physical triggers. The left ventricular ejection fraction (LVEF) was significantly lower in the pediatric population (30.5 + 10.4 vs 36.9 + 16.9, p < 0.05), resulting in more than fivefold rates of cardiogenic shock on admission compared to the general adult TTS population (Killip IV 74.1% vs 10.5%, p < 0.001) with similar rates of death and recurrence between groups. TTS in the pediatric population presents a distinctive clinical profile, with higher prevalence of atypical symptoms and physical triggers, as well as higher rates of cardiogenic shock on admission and similar mortality and recurrence rates than those of the adult population. This study provides valuable insights into understanding pediatric TTS and underscores the necessity for further research in this age group.

Renal impairment and outcome in Takotsubo syndrome: Insights from a national multicentric cohort.

INTRODUCTION: Data on the association between kidney function and Takotsubo syndrome (TTS) outcomes are scarce and conflictive. OBJECTIVE: To assess the impact of chronic kidney disease (CKD) and acute renal failure (ARF) in patients with TTS. MATERIAL AND METHODS: Patients from the prospective nation-wide (RETAKO) registry were included and divided into quartiles of maximum creatinine (Cr) level during hospitalization. RESULTS: The prevalence of CKD and ARF in the whole RETAKO cohort was 5.4% and 11.7%, respectively. Compared to Q1 (Cr <0.71), patients within Q4 (Cr > 1.1) had lower left ventricular ejection fraction on admission (38.5 ± 12 vs 43.3 ± 11.3, p = 0.002) and higher bleeding rates during hospitalization (6.7% vs 2%, p = 0.005). In addition, compared to Q1, Q4 patients have a greater incidence of cardiogenic shock (17.3% vs 5.6%, p < 0.001), and a higher rate of 5-year all-cause death and major adverse cardiovascular events (31.5% vs 15.8%, p < 0.001 and 22.5% vs 9.3%, p < 0.001, respectively). CONCLUSIONS: TTS patients with CKD have a higher incidence of ARF and exhibit greater Cr on admission, which were linked with higher rates of cardiogenic shock, bleeding during hospitalization as well as major adverse cardiovascular events and all-cause death during a 5-year follow-up.

Impact of mechanical circulatory support on outcomes in Takotsubo syndrome complicated by cardiogenic shock: Insights from the RETAKO registry.

BACKGROUND: Cardiogenic shock (CS) complicates Takotsubo syndrome (TTS), significantly affecting patient outcomes. Since avoiding catecholamines, particularly inotropic agents, is recommended in TTS, temporary mechanical circulatory support (MCS) shows promise as a bridge to recovery. However, there is no prospective data on its use in TTS. METHODS: Patients from the prospective nationwide RETAKO registry were included and divided based on the use and type of MCS. RESULTS: From a national TTS registry, 1591 consecutive patients were initially enrolled between 2003 and 2022. Of these, 322 patients (20.2 %) developed CS, and 31 (9.6 %) were treated with MCS [20 intra-aortic balloon pump (IABP) (64.5 %), 8 veno-arterial extracorporeal membrane oxygenation (25.8 %), and 3 Impella-CP (9.7 %)]. Compared to CS patients managed only with drugs, MCS recipients exhibited a more severe clinical profile, with worse ventricular function and more right ventricular involvement. Despite encountering more complications, such as major bleeding and atrial fibrillation, MCS did not significantly influence in-hospital mortality (19.4 % in the MCS group vs 13.1 % in the no MCS group, p = 0.33). After adjusting for other predictors of in-hospital mortality (invasive mechanical ventilation, inotropic-vasoactive score, age, and SCAI stage), MCS was not associated with higher mortality. CONCLUSION: Approximately 10 % of TTS patients complicated by CS were treated with MCS. Despite their more severe CS, patients treated with MCS had similar in-hospital mortality rates as those treated only with drugs, suggesting a potential benefit of MCS in selected cases.

Recovery of Left Ventricular Function and Long-Term Outcomes in Patients With Takotsubo Syndrome.

BACKGROUND: Takotsubo syndrome (TTS) is a form of transient left ventricular (LV) dysfunction that usually resolves within days to weeks. OBJECTIVES: We aimed to assess the predictors and prognostic impact of time-to-LV recovery after TTS. METHODS: Prospective serial imaging data from the nationwide, multicenter RETAKO (REgistry on TAKOtsubo Syndrome) were comprehensively reviewed to assess the timing of LV recovery. Multivariable logistic regression was used to assess factors associated with late (≥10 days) vs early (<10 days) recovery. The long-term risk of all-cause mortality was compared between the late and early recovery groups using fully adjusted Cox models, and using flexible parametric survival models with recovery time included as a continuous variable. RESULTS: Of 1,463 patients included (median age 73 years, 13% men), 373 (25%) had late and 1,090 (75%) had early LV recovery. Older age, history of neurological disorders, bystander coronary artery disease, active cancer, physical triggers, elevated inflammatory biomarkers, cardiogenic shock, and lower LV ejection fraction at admission were independent predictors of late recovery. At 4-year follow-up, the adjusted risk of death was significantly higher in patients with late recovery compared with those with early recovery (16.0% vs 8.6%, adjusted HR: 1.31; 95% CI: 1.12-1.60), with the risk of death increasing by 8% for every additional 10-day delay in time-to-LV recovery (adjusted HR: 1.08; 95% CI: 1.04-1.13). CONCLUSIONS: Late recovery of LV function after TTS is associated with reduced short- and long-term survival. In TTS patients without early LV recovery, closer clinical follow-up might be considered.

Peripartum Takotsubo Cardiomyopathy: A Review and Insights from a National Registry.

Takotsubo syndrome (TTS) during the peripartum period is a relevant cause of morbidity in this population; its clinical course and prognosis, compared to the general TTS population, is yet to be elucidated. Our aim was to analyze the clinical features and prognosis of peripartum TTS in a nationwide prospective specifically oriented registry database and consider the published literature. Peripartum TTS patients from the prospective nationwide RETAKO registry-as well as peripartum TTS patients from the published literature-were included, and multiple comparisons between groups were performed in order to assess for statistically and clinically relevant prognostic differences between the groups. Patients with peripartum TTS exhibit a higher prevalence of secondary forms, dyspnea, atypical symptoms, and echocardiographic patterns, as well as less ST-segment elevation than the general TTS population. In the literature, patients with peripartum TTS had a higher Killip status on admission. TTS during the peripartum period has a higher prevalence of angina and dyspnea, as well as physical triggers, neither of which are related to a worse prognosis. Killip status on admission was higher in the literature for patients with TTS but with excellent mid- and long-term prognoses after the acute phase, despite mostly being secondary forms.

His bundle pacing success and electrical parameter stability regardless of three-dimensional transthoracic echocardiography lead localization.

BACKGROUND OR PURPOSE: His bundle pacing (HBP) is the most physiological form of ventricular pacing. Few prospective studies have analyzed lead localization using imaging techniques and its relationship with electrical parameters and capture patterns. The objective of this study is to examine the correlation between electrical parameters and lead localization using three-dimensional transthoracic echocardiography (3D TTE). METHODS: This single-center, prospective, nonrandomized clinical research study (January 2018 to June 2020) included patients with an indication of permanent pacing, in whom 3D TTE was performed to define lead localization as supravalvular or subvalvular. RESULTS: A total of 92 patients were included: 56.5% of leads were supravalvular, and 43.5% were subvalvular, which resembles previous anatomic descriptions of autopsied hearts of His bundle localization within the triangle of Koch (ToK). R-wave sensing was higher when the His lead was localized subvalvular instead of supravalvular. His lead localization was not associated with HBP threshold or impedance differences, nor with the two different HBP patterns of capture, or with the ability of HBP to correct baseline BBB. The thresholds remained stable during follow-up visits, regardless of His lead localization. Higher R-wave sensing was observed during follow-up than at baseline, mainly in the subvalvular His leads. However, lead impedances in both positions decreased during follow-up. CONCLUSIONS: Lead localization in relation to the tricuspid valve did not influence the electrical performance of HBPs. Wide anatomical variations of the His bundle within the ToK explain our findings, reinforcing the idea that the technique for HBP should be fundamentally guided by electrophysiological and not anatomical parameters.

Improvement in electrocardiographic parameters of repolarization related to sudden death in patients with ventricular dysfunction and left bundle branch block after cardiac resynchronization through His bundle pacing.

BACKGROUND: Cardiac resynchronization therapy (CRT) through permanent His bundle pacing (p-HBP) normalizes interventricular conduction disorders and QRS. Similarly, there are immediate and long-term changes in repolarization, which could be prognostic of a lower risk of sudden death (SD) at follow-up. We aimed to compare the changes in different electrocardiographic (ECG) repolarization parameters related to the risk of SD before and after CRT through p-HBP. METHODS: In this prospective, descriptive single-center study (May 2019 to December 2021), we compared the ECG parameters of repolarization related to SD in patients with non-ischemic dilated cardiomyopathy, left bundle branch block (LBBB), and CRT indications, at baseline and after CRT through p-HBP. RESULTS: Forty-three patients were included. Compared to baseline, after CRT through p-HBP, there were immediate significant changes in the QT interval (ms): 445 [407.5-480] vs 410 [385-440] (p = 0.006), QT dispersion (ms): 80 [60-100] vs 40 [40-65] (p < 0.001), Tp-Te (ms): 90 [80-110] vs 80 [60-95] (p < 0.001), Tp-Te/QT ratio: 0.22 [0.19-0.23] vs 0.19 [0.16-0.21] (p < 0.001), T wave amplitude (mm): 6.25 [4.88-10] vs - 2.5 [- 7-2.25] (p < 0.001), and T wave duration (ms): 190 [157.5-200] vs 140 [120-160] (p = 0.001). In the cases of the corrected QT (Bazzett and Friederichia) and the Tp-Te dispersion, changes only became significant at 1 month post-implant (468.5 [428.8-501.5] vs 440 [410-475.25] (p = 0.015); 462.5 [420.8-488.8] vs 440 [400-452.5] (p = 0.004), and 40 [30-52.5] vs 30 [20-40] (p < 0.001), respectively) (Table 1). Finally, two parameters did not improve until 6 months post-implant: the rdT/JT index, 0.25 [0.21-0.28] baseline vs 0.20 [0.19-0.23] 6 months post-implant (p = 0.011), and the JT interval, 300 [240-340] baseline vs 280 [257-302] 6 months post-implant (p = 0.027). Additionally, most of the parameters continued improving as compared with immediate post-implantation. CONCLUSIONS: After CRT through His bundle pacing and LBBB correction, there was an improvement in all parameters of repolarization related to increased SD reported in the literature.