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Three Recurrent Episodes of Apical-Ballooning Takotsubo Cardiomyopathy in a Man

2015; Lippincott Williams & Wilkins; Volume: 132; Issue: 24 Linguagem: Inglês

10.1161/circulationaha.115.017630

1524-4539

Mattia Cattaneo, Marco Moccetti, Elena Pasotti, Francesco F. Faletra, Alessandra Pia Porretta, Richard Kobza, Augusto Gallino,

Electroconvulsive Therapy Studies

HomeCirculationVol. 132, No. 24Three Recurrent Episodes of Apical-Ballooning Takotsubo Cardiomyopathy in a Man Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBThree Recurrent Episodes of Apical-Ballooning Takotsubo Cardiomyopathy in a Man Mattia Cattaneo, MD, Marco Moccetti, MD, Elena Pasotti, MD, Francesco Faletra, MD, Alessandra P. Porretta, MD, Richard Kobza, MD and Augusto Gallino, MD Mattia CattaneoMattia Cattaneo From Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli–San Giovanni, Bellinzona, Switzerland (M.C., A.P.P., A.G.); Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (M.M., E.P., F.F.); Luzerner Kantonsspital, Luzern, Switzerland (R.K.); and University of Zurich, Switzerland (A.G.). , Marco MoccettiMarco Moccetti From Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli–San Giovanni, Bellinzona, Switzerland (M.C., A.P.P., A.G.); Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (M.M., E.P., F.F.); Luzerner Kantonsspital, Luzern, Switzerland (R.K.); and University of Zurich, Switzerland (A.G.). , Elena PasottiElena Pasotti From Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli–San Giovanni, Bellinzona, Switzerland (M.C., A.P.P., A.G.); Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (M.M., E.P., F.F.); Luzerner Kantonsspital, Luzern, Switzerland (R.K.); and University of Zurich, Switzerland (A.G.). , Francesco FaletraFrancesco Faletra From Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli–San Giovanni, Bellinzona, Switzerland (M.C., A.P.P., A.G.); Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (M.M., E.P., F.F.); Luzerner Kantonsspital, Luzern, Switzerland (R.K.); and University of Zurich, Switzerland (A.G.). , Alessandra P. PorrettaAlessandra P. Porretta From Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli–San Giovanni, Bellinzona, Switzerland (M.C., A.P.P., A.G.); Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (M.M., E.P., F.F.); Luzerner Kantonsspital, Luzern, Switzerland (R.K.); and University of Zurich, Switzerland (A.G.). , Richard KobzaRichard Kobza From Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli–San Giovanni, Bellinzona, Switzerland (M.C., A.P.P., A.G.); Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (M.M., E.P., F.F.); Luzerner Kantonsspital, Luzern, Switzerland (R.K.); and University of Zurich, Switzerland (A.G.). and Augusto GallinoAugusto Gallino From Cardiovascular Medicine Department, Ospedale Regionale di Bellinzona e Valli–San Giovanni, Bellinzona, Switzerland (M.C., A.P.P., A.G.); Department of Cardiology, Fondazione Cardiocentro Ticino, Lugano, Switzerland (M.M., E.P., F.F.); Luzerner Kantonsspital, Luzern, Switzerland (R.K.); and University of Zurich, Switzerland (A.G.). Originally published15 Dec 2015https://doi.org/10.1161/CIRCULATIONAHA.115.017630Circulation. 2015;132:e377–e379A 66-year-old man was admitted to the emergency room because of 3-hour-long acute chest pain with dyspnea and nausea while fishing on a high-altitude (2400 m) lake in the very early morning. The patient was transferred by helicopter. Persistent chest pain without pathological clinical findings (Spo2, 99%; shock index, 0.9; axillary temperature, 36.7°C) was present. Medical history revealed no previous cardiovascular events and no further cardiovascular risk factors except smoking (40 packs a year). ECG demonstrated ST-segment elevation (Figure 1A). ST-segment–elevation acute coronary syndrome was initially suspected. Immediate selective coronary angiography demonstrated neither stenosis nor dissections. Ventriculography showed extensive left ventricular (LV) apical and midventricular akinesia with hyperkinesia in the basal segments and a moderate reduction in the estimated LV ejection fraction (Figure 1B and Movie I in the online-only Data Supplement). These large LV wall motion abnormalities were inconsistent with slightly elevated cardiac enzymes (troponin I, 0.48 μg/L [normal, <0.09 μg/L]; creatine kinase-MB, 18.7 UI/L [normal, <24 UI/L]). Clinical presentation and the absence of elevation of inflammation markers elevation and pathological viral tests and bacterial cultures made it possible to reasonably exclude acute myocarditis. ECG repolarization alteration (Figure 1C) and LV wall motion abnormalities recovered spontaneously and fully in 4 days (Figure 1D and Movie II in the online-only Data Supplement). Therefore, the diagnosis of apical-ballooning takotsubo cardiomyopathy (TTC) was made.Download figureDownload PowerPointFigure 1. A, ECG showing ST-segment elevation in the precordial leads. B, Ventriculography (longitudinal view, end systole) illustrates extensive left ventricular (LV) apical and midventricular akinesia (arrows) with hyperkinesia in the basal segments and moderately reduced LV ejection fraction (Movie I in the online-only Data Supplement). C, ECG shows spontaneously normalized repolarization within 4 days and left anterior fascicular block. D, Transthoracic echocardiography (4-chamber view, end systole) shows fully recovered LV wall motion abnormalities with normal ejection fraction within 4 days (Movie II in the online-only Data Supplement).One year later, the patient, who incidentally stopped smoking after the TTC episodes, was admitted to the emergency room of another hospital because of acute chest pain. No precipitating episode was identified. ECG (Figure 2A), troponin I, blood samples, transthoracic echocardiography, selective coronary angiography, and LV volume (Figure 2B and Movie III in the online-only Data Supplement) displayed findings comparable with the previous episode. Furthermore, exclusion of late gadolinium enhancement on magnetic resonance imaging made it possible to exclude myocarditis. ECG repolarization alteration (Figure 2C) recovered fully and spontaneously. Four weeks after admission, transthoracic echocardiography demonstrated full recovery of the LV wall motion abnormalities (Figure 2D and Movie IV in the online-only Data Supplement), consistent with a diagnosis of a recurrent TTC.Download figureDownload PowerPointFigure 2. A, ECG showing T-wave inversion in inferior leads and precordial leads V3 through V6. B, Ventriculography (longitudinal view, end systole) proves extensive left ventricular (LV) apical and midventricular akinesia (arrows) with hyperkinesia in the basal segments and moderately reduced LV ejection fraction (Movie III in the online-only Data Supplement). C, ECG shows spontaneously normalized repolarization within 1 day and left anterior fascicular block. D, Transthoracic echocardiography (2-chamber view, end systole) shows fully reversible LV wall motion abnormalities with normal ejection fraction within 4 weeks (Movie IV in the online-only Data Supplement).Two years later, the patient was admitted again to the emergency room of a small district hospital because of acute chest pain and dyspnea while fishing on a lake on a cold morning. ECG showed T-wave inversion in the inferior leads and precordial leads V3 through V6 (Figure 3A). The patient was transferred to primary percutaneous coronary intervention–capable center, where transthoracic echocardiography, selective coronary angiography, and LV volume (Figure 3B and Movie V in the online-only Data Supplement) were comparable with those of the 2 preceding episodes (troponin I, 4.06 μg/L; creatine kinase-MB, 38 UI/L). ECG repolarization alteration (Figure 3C) recovered fully and spontaneously, and LV wall motion abnormalities recovered spontaneously and completely within 1 week (Figure 3D and Movie VI in the online-only Data Supplement). Therefore, the diagnosis of a third typical TTC episode was confirmed.Download figureDownload PowerPointFigure 3. A, ECG showing T-wave inversion in inferior leads and precordial leads V4 through V6. B, Transthoracic echocardiography (TTE; 4-chamber view, end systole) shows extensive left ventricular (LV) apical akinesia and midventricular hypokinesia (arrows; Movie V in the online-only Data Supplement). C, ECG shows spontaneously normalized repolarization within 2 days and left anterior fascicular block. D, TTE (4-chamber view, end systole) demonstrates fully recovered LV wall motion abnormalities with normal ejection fraction within 1 week (Movie VI in the online-only Data Supplement).Normal 24-hour urine fractionated catecholamines and metanephrines and the absence of hypertension made it improbable that pheochromocytoma was the cause of these 3 TTC episodes.TTC is an infrequent, mostly stress-related disease, affecting mainly postmenopausal women. Even rarer are recurrences (1.5%/y–2.9%/y),1,2 mostly seen in menopausal woman and frequently with different LV wall motion abnormality patterns.3,4 To the best of our knowledge, this is the first reported case of 3 episodes of recurrent typical apical-ballooning TTC in an adult man. Moreover, this case underscores that both invasive ventriculography and transthoracic echocardiography should be implemented to obtain a correct diagnosis and during follow-up.DisclosuresNone.FootnotesCorrespondence to Mattia Cattaneo, MD, Department of Cardiovascular Medicine, Ospedale Regionale di Bellinzona e Valli, San Giovanni, 6500 Bellinzona, Switzerland. E-mail [email protected]References1. Singh K, Carson K, Usmani Z, Sawhney G, Shah R, Horowitz J. Systematic review and meta-analysis of incidence and correlates of recurrence of takotsubo cardiomyopathy.Int J Cardiol. 2014; 174:696–701. doi: 10.1016/j.ijcard.2014.04.221.CrossrefMedlineGoogle Scholar2. Elesber AA, Prasad A, Lennon RJ, Wright RS, Lerman A, Rihal CS. Four-year recurrence rate and prognosis of the apical ballooning syndrome.J Am Coll Cardiol. 2007; 50:448–452. doi: 10.1016/j.jacc.2007.03.050.CrossrefMedlineGoogle Scholar3. Xu B, Williams PD, Brown M, Macisaac A. Takotsubo cardiomyopathy: does recurrence tend to occur in a previously unaffected ventricular wall region?Circulation. 2014; 129:e339–e340. doi: 10.1161/CIRCULATIONAHA.113.007015.LinkGoogle Scholar4. Chattopadhyay S, John J. Tako-tsubo and reverse tako-tsubo cardiomyopathy: temporal evolution of the same disease?Eur Heart J. 2009; 30:2837. doi: 10.1093/eurheartj/ehp430.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Korabathina R, Porcadas J, Kip K, Korabathina P, Rosenthal A and Wassmer P (2021) Left Ventricular Ballooning Patterns in Recurrent Takotsubo Cardiomyopathy: A Systematic Review and Meta-analysis of Reported Cases, Texas Heart Institute Journal, 10.14503/THIJ-20-7223, 48:5, Online publication date: 1-Nov-2021. Nomura T, Sakaue Y, Ono K, Wada N, Sia C, Arcari L, Anagnostopoulou A, Tindale A and Sunjaya A (2021) Five recurrent episodes of Takotsubo syndrome provoked by various triggers over a period of 7 years: a case report, European Heart Journal - Case Reports, 10.1093/ehjcr/ytab431, 5:11, Online publication date: 1-Nov-2021. Adigun R, Morley S and Prasad A (2018) Rare recurrence of apical ballooning (takotsubo) syndrome in an elderly man, BMJ Case Reports, 10.1136/bcr-2017-222451, (bcr-2017-222451) Ghadri J, Wittstein I, Prasad A, Sharkey S, Dote K, Akashi Y, Cammann V, Crea F, Galiuto L, Desmet W, Yoshida T, Manfredini R, Eitel I, Kosuge M, Nef H, Deshmukh A, Lerman A, Bossone E, Citro R, Ueyama T, Corrado D, Kurisu S, Ruschitzka F, Winchester D, Lyon A, Omerovic E, Bax J, Meimoun P, Tarantini G, Rihal C, Y.-Hassan S, Migliore F, Horowitz J, Shimokawa H, Lüscher T and Templin C (2018) International Expert Consensus Document on Takotsubo Syndrome (Part II): Diagnostic Workup, Outcome, and Management, European Heart Journal, 10.1093/eurheartj/ehy077, 39:22, (2047-2062), Online publication date: 7-Jun-2018. Madias J (2016) Letter by Madias Regarding Article, "Three Recurrent Episodes of Apical-Ballooning Takotsubo Cardiomyopathy in a Man", Circulation, 133:19, (e655-e655), Online publication date: 10-May-2016.Alla V and Kaushik M (2016) Letter by Alla and Kaushik Regarding Article, "Three Recurrent Episodes of Apical-Ballooning Takotsubo Cardiomyopathy in a Man", Circulation, 133:19, (e654-e654), Online publication date: 10-May-2016. Vitale C, Rosano G and Kaski J (2016) Role of Coronary Microvascular Dysfunction in Takotsubo Cardiomyopathy, Circulation Journal, 10.1253/circj.CJ-15-1364, 80:2, (299-305), . December 15, 2015Vol 132, Issue 24 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.017630PMID: 26667101 Originally publishedDecember 15, 2015 PDF download Advertisement SubjectsAcute Coronary SyndromesEtiologyImaging