Resolution of Acute Respiratory Distress Syndrome-Induced Takotsubo Cardiomyopathy with Venovenous Extracorporeal Membrane Oxygenation.

INTRODUCTION: Takotsubo cardiomyopathy (TTCM) can occur in acute respiratory distress syndrome (ARDS) and a few cases in literature were reported to be associated with hemodynamic instability. All these patients were managed with venoarterial extracorporeal membrane oxygenation (VA-ECMO).Case presentation: We present two patients with ARDS-induced TTCM who were managed successfully with venovenous ECMO (VV-ECMO). CONCLUSION: Ventricular function in both patients fully recovered three days after ECMO initiation, and they were subsequently weaned from ECMO once pulmonary function improved.

Development of Takotsubo cardiomyopathy following spontaneous coronary artery dissection in a patient with fibromuscular dysplasia.

New-onset Takotsubo cardiomyopathy following spontaneous coronary artery dissection (SCAD) is rare. We report a middle-aged woman without significant cardiovascular risk factors, who initially presented with non-ST-elevation myocardial infarction (NSTEMI) with angiography showing sudden 'pruning' of the coronary artery consistent with SCAD. One week later, the patient returned with recurrent NSTEMI. Repeat coronary angiogram showed no change in SCAD, but ventriculogram revealed new-onset apical ballooning beyond the SCAD-affected territory, consistent with Takotsubo cardiomyopathy. Further head-to-pelvis angiogram revealed an irregular beaded appearance of the left vertebral artery consistent with fibromuscular dysplasia. The patient was managed conservatively with aspirin, carvedilol and escitalopram with complete resolution of cardiac and mood symptoms. Our case supports an association between SCAD and Takotsubo cardiomyopathy in a potentially mutually aggravating process. Clinical vigilance is therefore required to rule out the other condition when one of the two entities is diagnosed.

Patent Foramen Ovale and Coronary Artery Spasm: A New Patent Foramen Ovale-associated Condition that May Explain the Mechanism of Vasospastic Angina.

Patent foramen ovale (PFO) may be an underlying factor in the pathogenesis of migraine, vasospastic angina, and Takotsubo cardiomyopathy. This article reviews the role that PFO may play in each of these clinical entities and discusses potential interventions. It also proposes a novel clinical syndrome wherein PFO may be the unifying link among migraine, coronary vasospasm, and Takotsubo cardiomyopathy in predisposed individuals.

Acute myocardial infarction or Takotsubo syndrome in a patient with stunned myocardium due to myocardial bridging? A case report of diagnostic dilemma clarified after serial workup.

BACKGROUND: Myocardial bridging is a cardiac anomaly where a segment of epicardial coronary arteries runs through the myocardium and can rarely cause MI. Takotsubo syndrome is a stress-induced cardiomyopathy that can mimic MI. Catecholamine surge during stress can contribute to Takotsubo syndrome, but whether this surge can trigger an inconspicuous myocardial bridging to manifest symptomatically remains unclear, and alternately, whether a myocardial bridge might cause worsening of Takotsubo syndrome is also a matter that needs further research. CASE PRESENTATION: We report the case of a patient who initially presented with features of acute exacerbation of bronchiectasis and subsequently developed symptoms and ECG features suggestive of acute myocardial infarction. Echocardiography revealed features of takotsubo syndrome, and complete myocardial bridging was revealed via coronary angiography. The patient was managed conservatively with pharmacological treatment, and after a few days, echocardiographic features were reversed. As such, the diagnosis shifted toward Takotsubo syndrome with myocardial stunning due to co-existent myocardial bridging. CONCLUSION: We report a rare case of a patient with acute bronchiectasis exacerbation with features suggestive of acute myocardial infarction who had findings of Takotsubo syndrome and complete myocardial bridging. In the beginning, it was difficult to determine whether the symptoms arose due to acute MI resulting from myocardial bridging or were solely due to takotsubo syndrome because of stress from bronchiectasis. Although myocardial bridging is often overlooked as an etiology for acute MI, this case highlights the importance of expanding the differential diagnosis to myocardial bridging in the work-up for the cause of acute MI and how Takotsubo syndrome can mimic acute MI and pose a diagnostic challenge.

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.

Complex Presentation of Pheochromocytoma: Hypertensive Encephalopathy and Takotsubo-Like Cardiomyopathy in a Young Female.

BACKGROUND Pheochromocytoma, a rare catecholamine-secreting tumor, often presents with paroxysmal or sustained hypertension, tachycardia, headache, and diaphoresis. Timely diagnosis is essential to prevent adverse complications. Less common presentations include pheochromocytoma crisis, with severe neurological and cardiac complications. CASE REPORT We report a unique case of a 25-year-old woman who initially presented with pheochromocytoma-induced hypertensive encephalopathy and acute coronary syndrome. Echocardiography revealed takotsubo-like cardiomyopathy, and magnetic resonance imaging of the brain revealed posterior reversible encephalopathy syndrome. Initial treatment focused on controlling her blood pressure and supporting cardiac function. Due to her recovering from immediate crisis and absence of further symptoms, the patient refused further follow-up. However, she eventually experienced another episode of hypertensive crisis 2 years later. Subsequent investigations with 24-h urine tests revealed elevated vanillylmandelic acid levels (7.93 mg/24 h), normetanephrine (2638.72 µg/24 h), and nor-metanephrine to creatinine ratio (3546.67) and normal urine metanephrine levels (195.92 µg/24 h) and metanephrine to creatinine ratio (263.33). Contrast-enhanced computed tomography of the abdomen revealed a 4.3×3.1×4-cm mass in the right adrenal gland. A DOTATATE positron emission tomography scan revealed a 3.9×4.3×2.7-cm localized right adrenal pheochromocytoma. Biochemical testing and adrenal imaging revealed a previously undiagnosed pheochromocytoma. Following targeted medical therapy and right adrenalectomy, the patient achieved complete resolution of her hypertension and associated symptoms. CONCLUSIONS Our case is a unique simultaneous presentation of posterior reversible encephalopathy syndrome and takotsubo-like cardiomyopathy, highlighting the importance to consider pheochromocytoma in acute neurological and cardiac presentations, even in the absence of typical symptoms.

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.

Rapid identification and management of stress-induced cardiomyopathy using POCUS after strangulation: A case report.

RATIONALE: Stress-induced cardiomyopathy (SCMP), also known as Takotsubo syndrome, is a transient cardiac condition often precipitated by severe emotional or physical stress. It is commonly mistaken for acute coronary syndrome due to similar clinical presentations. The use of point-of-care ultrasound (POCUS) provides a noninvasive, rapid diagnostic alternative that can potentially reduce the need for invasive coronary angiography, especially in emergency settings. PATIENT CONCERNS: A 26-year-old woman with type 1 diabetes presented to the emergency department following a suicidal hanging attempt. Upon arrival, she was conscious but confused, with stable vital signs. There were visible signs of strangulation, but no other immediate physical abnormalities. Laboratory tests revealed elevated cardiac enzymes and hyperglycemia. DIAGNOSES: Initial bedside POCUS revealed a reduced ejection fraction and regional wall motion abnormalities in the midportion of the left ventricle, suggesting SCMP. These findings, combined with the patient's history and absence of other contributory factors, led to a provisional diagnosis of SCMP. INTERVENTIONS: The patient was admitted to the intensive care unit for close monitoring. Serial POCUS examinations were performed to track cardiac function. Due to the rapid improvement in regional wall motion abnormalities observed through POCUS, the planned coronary angiography was deferred. OUTCOMES: The patient exhibited significant clinical improvement within 24 hours, with normalization of cardiac function as demonstrated by follow-up POCUS. Cardiac enzyme levels also returned to normal. The patient was discharged directly from the intensive care unit without the need for further invasive procedures. LESSONS: This case underscores the diagnostic value of POCUS in rapidly identifying SCMP in emergency settings, which can guide timely and appropriate management. The noninvasive nature of POCUS may reduce the need for invasive diagnostics, minimize hospital stay duration, and enhance cost-effectiveness in managing SCMP.

Intraoperative Reverse Takotsubo Cardiomyopathy in Liver Transplantation: An Anesthesiologist's Nightmare.

BACKGROUND: Reverse Takotsubo cardiomyopathy (TTC) is a rare variant of stress cardiomyopathy, characterized by basal akinesia with apical sparing. To our knowledge, this case is the first reported in the literature of intraoperative reverse TTC (rTTC) in liver transplantation. CASE: After a thorough workup, a 19-year-old man, diagnosed with extrahepatic biliary atresia, was taken up for living-related donor liver transplantation. The patient developed intraoperative rTTC. This case report describes the challenges and successful management of this cardiomyopathy intraoperatively and postoperatively. CONCLUSION: Intraoperative rTTC is challenging and requires aggressive and immediate hemodynamic and pharmacological management, along with supportive treatment and management of complications. This case report describes the challenges and successful management of this cardiomyopathy intraoperatively and postoperatively. To our knowledge, this case is the first reported in the literature of intraoperative rTTC in liver transplantation.

Takotsubo cardiomyopathy associated with free wall rupture and ventricular septal defect: a case report.

Takotsubo cardiomyopathy is a rare cardiac presentation. It can be associated with severe complications such as hemodynamically significant ventricular septal defect and cardiac free wall rupture. In cases of mechanical complications, surgical repair is often indicated. Despite best medical and surgical efforts, patients with Takotsubo cardiomyopathy and mechanical complications carry significant mortality risk. Herein, we present an unusual presentation of Takotsubo cardiomyopathy that was associated with a mechanical complication. Although the patient underwent a successful surgical repair, she passed away from multiorgan failure during the postoperative period.

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Cardiogenic shock in takotsubo syndrome: etiology and treatment.

Takotsubo syndrome (TTS) can mimic acute coronary syndrome despite being a distinct disease. While typically benign, TTS can lead to serious complications like cardiogenic shock. Cardiogenic shock occurs in 1-20% of TTS cases. Various mechanisms can cause shock, including pump failure, right ventricular involvement, left ventricular outflow tract obstruction, and acute mitral regurgitation. Because treatment depends on the mechanism, early identification of the mechanism developing cardiogenic shock is essential for optimal treatment and improved outcomes in TTS patients with cardiogenic shock. This review summarizes current knowledge on causes and treatment of cardiogenic shock in patients with TTS.

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.

Perioperative Takotsubo Stress Cardiomyopathy During Endoscopic Spinal Surgery: A Case Report.

CASE: A 37-year-old man American Society of Anesthesiologists grade 1 patient with lumbar canal stenosis at the L4-L5 level underwent endoscopic decompression. Toward the end of the procedure, the patient developed sudden-onset bradycardia, followed by ventricular arrhythmia and acute pulmonary edema. The patient was successfully managed with resuscitation and supportive management and recovered uneventfully thereafter. A diagnosis of perioperative stress cardiomyopathy was subsequently made after evaluation of the patient. CONCLUSION: The possibility of takotsubo cardiomyopathy should be considered in cases of acute perioperative cardiac decompensation and pulmonary edema in patients undergoing spinal surgery.

The role of inflammation in takotsubo syndrome: A new therapeutic target?

Takotsubo syndrome (TTS) is a particular form of acute heart failure that can be challenging to distinguish from acute coronary syndrome at presentation. TTS was previously considered a benign self-limiting condition, but it is now known to be associated with substantial short- and long-term morbidity and mortality. Because of the poor understanding of its underlying pathophysiology, there are few evidence-based interventions to treat TTS. The hypotheses formulated so far can be grouped into endogenous adrenergic surge, psychological stress or preexisting psychiatric illness, coronary vasospasm with microvascular dysfunction, metabolic and energetic alterations, and inflammatory mechanisms. Current evidence demonstrates that the infiltration of immune cells such as macrophages and neutrophils play a pivotal role in TTS. At baseline, resident macrophages were the dominant subset in cardiac macrophages, however, it underwent a shift from resident macrophages to monocyte-derived infiltrating macrophages in TTS. Depletion of macrophages and monocytes in mice strongly protected them from isoprenaline-induced cardiac dysfunction. It is probable that immune cells, especially macrophages, may be new targets for the treatment of TTS.

[Takotsubo syndrome in dengue patient]. / Síndrome de Takotsubo en paciente con dengue.

Takotsubo syndrome, was described in Japan in 1990, it is a stress cardiomyopathy, predominantly in women, usually postmenopausal. Cardiac hypokinesia occurs, with involvement of multiple coronary territories. In intensive care unit (ICU), it is considered underdiagnosed. Manifestations of severe dengue fever include cardiovascular involvement, mainly arrhythmias and systolic dysfunction. A case of a 72-year-old man is presented, who was hospitalized in ICU for dengue fever, with plateletopenia (15000 cells/mm3) and dehydration. After fluid management the patient reported respiratory discomfort, auscultating crackling rales. A pulmonary ultrasound was made where bilateral B lines were found with B7 pattern compatible with interstitial syndrome and pulmonary edema. Basal hyperkinesia, medial and apical hypokinesia with an image consistent with apical ballooning were observed in the transthoracic echocardiogram. The electrocardiogram showed complete right bundle branch block. Chagas serology was negative and quantitative troponin I was increased. In the context of severe dengue, a Takotsubo syndrome was diagnosed. The patient evolved favorably. After discharge, a normalization of the cardiac function was stated in ultrasound images. The case is of clinical importance due to the low association of these two diseases and the need to screen for cardiac involvement in severe dengue.

El síndrome de Takotsubo, fue descripto en Japón en 1990, se trata de una miocardiopatía por estrés, predominante en mujeres, generalmente postmenopáusicas. Se produce una hipoquinesia cardiaca, con compromiso de múltiples territorios coronarios. En las unidades de terapia intensiva (UTI), se considera subdiagnosticada. En las manifestaciones del dengue grave, se encuentra el compromiso cardiovascular, principalmente arritmias y disfunción sistólica. Se presenta el caso de un hombre de 72 años, internado en UTI por dengue, con plaquetopenia (15000 células/mm3) y deshidratación. Luego de la administración de fluidos refirió disconfort respiratorio, auscultándose estertores pulmonares. Se realizó ecografía pulmonar donde se apreció líneas B bilaterales con patrón B7 compatible con síndrome intersticial y edema pulmonar. En el ecocardiograma transtorácico se objetivó hiperquinesia basal, hipoquinesia medial y apical con imagen compatible con balonamiento apical. En el electrocardiograma se evidenció bloqueo completo de rama derecha. La serología para Chagas fue negativa y la troponina I cuantitativa se detectó aumentada. Se diagnosticó síndrome de Takotsubo en el contexto de dengue grave. El paciente evolucionó favorablemente. Posterior al alta, se constató normalización de la motilidad cardíaca, en las imágenes ecográficas. El caso es de importancia clínica por la baja asociación de las dos enfermedades y la necesidad de pesquisar el compromiso cardíaco en el dengue grave.

Takotsubo cardiomyopathy following pacemaker insertion complicated with polymorphic ventricular tachycardia: a case report.

BACKGROUND: Takotsubo cardiomyopathy is a novel form of rapidly reversible heart failure occurring secondary to a stressor that mimics an acute coronary event. The underlying etiology of the stressor is highly variable and can include medical procedures. Pacemaker insertion is an infrequent cause of Takotsubo cardiomyopathy. CASE PRESENTATION: An 86-year-old Caucasian woman underwent an uncomplicated pacemaker insertion for symptomatic complete heart block in the background of slow atrial fibrillation. A transient episode of polymorphic ventricular tachycardia was noted on day 1 following the procedure; however, her pacemaker was checked and, as she remained stable, she was discharged home. She presented again 5 days later with symptomatic heart failure. Chest X-ray confirmed pulmonary edema. Echocardiography confirmed new onset severe left ventricle dysfunction. Pacemaker checks were normal and lead placement was confirmed. Though her troponin I was elevated, her coronary angiogram was normal. Contrast enhanced echocardiography suggested apical ballooning favoring Takotsubo cardiomyopathy. She was treated for heart failure and made a good recovery. Her follow-up echocardiography a month later showed significant improvement in left ventricle function. CONCLUSIONS: Takotsubo cardiomyopathy is mediated by a neuro-cardiogenic mechanism due to hypothalamic-pituitary-adrenal axis activation. It generally has a good prognosis. Complications though uncommon, can occur and include arrhythmias. Pacemaker insertion as a precipitant stressor is an infrequent cause of Takotsubo cardiomyopathy. As pacemaker insertions are more frequent in the elderly age group, this phenomenon should be recognized as a potential complication.

Current US prevalence of myocardial injury patterns and clinical outcomes among hospitalised patients with familial hypercholesterolaemia: insight from the National Inpatient Sample-a retrospective cohort study.

BACKGROUND: Familial hypercholesterolaemia (FH) increases propensity for premature atherosclerotic disease. Knowledge of inpatient outcomes among patients with FH admitted with acute myocardial injury (AMI) is limited. OBJECTIVES: Our study aimed to identify myocardial injury types, including type 1 myocardial infarction (MI), type 2 MI and takotsubo cardiomyopathy, assess lesion severity and study adverse short-term inpatient outcomes among patients with FH admitted with AMI. SETTING: Our study retrospectively queried the US National Inpatient Sample from 2018 to 2020. POPULATION: Adults admitted with AMI and dichotomised based on the presence of FH. STUDY OUTCOMES: We evaluated myocardial injury types and complexity of coronary revascularisation. Primary outcome of all-cause mortality and other clinical secondary outcomes were studied. RESULTS: There were 3 711 765 admissions with AMI including 2360 (0.06%) with FH. FH was associated with higher odds of ST-elevation MI (STEMI) (adjusted OR (aOR): 1.62, p<0.001) and non-ST-elevation MI (NSTEMI) (aOR: 1.29, p<0.001) but lower type 2 MI (aOR: 0.39, p<0.001) and takotsubo cardiomyopathy (aOR: 0.36, p=0.004). FH was associated with higher multistent percutaneous coronary interventions (aOR: 2.36, p<0.001), multivessel coronary artery bypass (aOR: 2.65, p<0.001), higher odds of intracardiac thrombus (aOR: 3.28, p=0.038) and mechanical circulatory support (aOR: 1.79, p<0.001). There was 50% reduction in odds of all-cause mortality (aOR: 0.50, p=0.006) and lower odds of mechanical ventilation (aOR: 0.37, p<0.001). There was no difference in rate of ventricular tachycardia, cardioversion, new implantable cardioverter defibrillator implantation, cardiogenic shock and cardiac arrest. CONCLUSION: Among patients hospitalised with AMI, FH was associated with higher STEMI and NSTEMI, lower type 2 MI and takotsubo cardiomyopathy, higher number of multiple stents and coronary bypasses, and mechanical circulatory support device but was associated with lower all-cause mortality and rate of mechanical ventilation.

Left ventricular outflow tract obstruction/hypertrophic cardiomyopathy/takotsubo syndrome: A new hypothesis of takotsubo syndrome pathophysiology.

The pathophysiology of TTS is still elusive. This viewpoint proposes that TTS is an acute coronary syndrome, engendered by an ASNS/catecholamine-induced LVOTO, which results in an enhanced wall stress and afterload-based supply/demand mismatch, culminating in a segmental myocardial ischemic injury state, in susceptible individuals. Such individuals are felt to be particularly women with chronic hypertension, known or latent HCM, or non-HCM segmental myocardial hypertrophy, and certain structural abnormalities involving the LV and the MV apparatus. Recommendations are provided to explore further this hypothesis, while maintaining our focus on all other advanced TTS pathophysiology hypotheses for all patients, or those who do not experience LVOTO, men, the young, and patients with reverse, mid-ventricular, or right ventricular TTS, in whom more prolonged hyperadrenergic stimulation and/or larger amounts of blood-ridden catecholamines, segmental particularities of cardiac innervation and/or density of α-, and ß-adrenergic receptors, pheochromocytoma, neurological chronic or acute comorbidities/catastrophies, coronary epicardial/microvascular vasospasm, and CMD.