The Heart of the Issue: A Case Report of Recurrent Reversible Stress-Induced Cardiomyopathy.

BACKGROUND Stress-induced cardiomyopathy is an increasingly recognized reversible cardiovascular condition. This type of cardiomyopathy usually occurs as an isolated event, and recurrent episodes are rare. Oftentimes, the underlying trigger is not recognized or definitively diagnosed. The differential diagnosis for reversible cardiomyopathy is extensive. A supraphysiologic catecholamine release from a pheochromocytoma can precipitate a recurrent and reversible cardiomyopathy. The highly variable clinical presentation of catecholamine-producing tumors can make timely recognition very challenging. CASE REPORT We present an exceptional case of recurrent reversible stress-induced cardiomyopathy triggered by an unrecognized pheochromocytoma with unusual clinical features. Our patient presented primarily with nonspecific neurological complaints, medication intolerance, and anxiety. The underlying etiology was not discovered until her fourth presentation of stress-induced cardiomyopathy. CONCLUSIONS Pheochromocytomas can have a highly variable clinical presentation with a broad spectrum of signs and symptoms. Our case highlights the importance of performing an exhaustive search for a definitive underlying cause in the setting of recurrent "stress-induced" cardiomyopathy. Providers should consider an underlying catecholamine-producing tumor when presented with recurrent reversible cardiomyopathy. We recommend using plasma, rather than urine, catecholamine studies to screen for the presence of a pheochromocytoma.

Posterior wall isolation using the cryoballoon in conjunction with pulmonary vein ablation is superior to pulmonary vein isolation alone in patients with persistent atrial fibrillation: A multicenter experience.

BACKGROUND: Pulmonary vein isolation (PVI) in conjunction with isolation of the posterior left atrial wall (PVI+PWI) is associated with improved clinical outcomes in certain patients with atrial fibrillation (AF). OBJECTIVE: The purpose of this multicenter study was to evaluate the acute and long-term outcomes of PVI+PWI vs PVI alone performed using cryoballoon ablation in patients with persistent AF (persAF). METHODS: We examined the procedural safety and efficacy and short- and long-term outcomes in 390 consecutive patients with persAF who underwent a first-time cryoballoon ablation procedure using PVI+PWI (n = 222 [56.9%]) vs PVI alone (n = 168 [43.1%]). RESULTS: Acute isolation was achieved in 99.7% of all pulmonary veins (PVI+PWI = 99.8% vs PVI alone = 99.3%; P = .23) using 6.3 ± 1.4 applications and 17 ± 2 minutes of cryoablation. PWI was achieved using 13.7 ± 3.2 applications and 34 ± 10 minutes of cryoablation. Adjunct radiofrequency ablation was required in 1.8% of patients to complete PVI (4 ± 2 minutes) and in 32.4% to complete PWI (5 ± 2 minutes). PVI+PWI yielded significantly greater posterior wall (77.2% ± 6.4% vs 40.6% ± 4.9%; P < .001) and total left atrial (53.3% ± 4.2% vs 36.3% ± 3.8%; P < .001) isolation. In addition, PVI+PWI was associated with greater AF termination (19.8% vs 8.9%; P = .003) and conversion to atrial flutters (12.2% vs 5.4%; P = .02). Adverse events were similar in both groups, whereas recurrence of AF and all atrial arrhythmias was lower with PVI+PWI at 12 months of follow-up. Moreover, in a Cox regression analysis, PVI+PWI emerged as a significant predictor of freedom from recurrent atrial arrhythmias (hazard ratio: 2.04; 95% confidence interval: 1.15-3.61; P = .015). CONCLUSION: PVI+PWI can be achieved safely and effectively using the cryoballoon. This approach appears superior to PVI alone in patients with persAF.