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      Reverse Takotsubo Cardiomyopathy: A Story of a Critically Ill Man with Transient Cardiac Dysfunction

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          Abstract

          Reverse Takotsubo cardiomyopathy (TCM) is a recently described variant of classic TCM. In contrast to classic TCM, the regional wall motion abnormalities are localized in the basal segments. The condition can be triggered by acute stressful events, including acute medical illnesses. The wall motion abnormalities and left ventricular dysfunction are usually completely reversible. We present a case of an 84-year-old man with a complicated postoperative course after laparoscopic cholecystectomy with multiple laparotomies and recurrent sepsis. Echocardiographic evaluation demonstrated left ventricular dysfunction and wall motion abnormalities in a pattern resembling reverse TCM. He had no significant coronary disease on angiography and follow-up echocardiography showed complete resolution of left ventricular systolic dysfunction and regional wall motion abnormalities.

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          Most cited references 7

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          Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: A systematic review.

          Transient left ventricular apical ballooning syndrome (TLVABS) is an acute cardiac syndrome mimicking ST-segment elevation myocardial infarction characterized by transient wall-motion abnormalities involving apical and mid-portions of the left ventricle in the absence of significant obstructive coronary disease. Searching the MEDLINE database 28 case series met the eligibility criteria and were summarized in a narrative synthesis of the demographic characteristics, clinical features and pathophysiological mechanisms. TLVABS is observed in 0.7-2.5% of patients with suspected ACS, affects women in 90.7% (95% CI: 88.2-93.2%) with a mean age ranging from 62 to 76 years and most commonly presents with chest pain (83.4%, 95% CI: 80.0-86.7%) and dyspnea (20.4%, 95% CI: 16.3-24.5%) following an emotionally or physically stressful event. ECG on admission shows ST-segment elevations in 71.1% (95% CI: 67.2-75.1%) and is accompanied by usually mild elevations of Troponins in 85.0% (95% CI: 80.8-89.1%). Despite dramatic clinical presentation and substantial risk of heart failure, cardiogenic shock and arrhythmias, LVEF improved from 20-49.9% to 59-76% within a mean time of 7-37 days with an in-hospital mortality rate of 1.7% (95% CI: 0.5-2.8%), complete recovery in 95.9% (95% CI: 93.8-98.1%) and rare recurrence. The underlying etiology is thought to be based on an exaggerated sympathetic stimulation. TLVABS is a considerable differential diagnosis in ACS, especially in postmenopausal women with a preceding stressful event. Data on longterm follow-up is pending and further studies will be necessary to clarify the etiology and reach consensus in acute and longterm management of TLVABS.
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            Proposed Mayo Clinic criteria for the diagnosis of Tako-Tsubo cardiomyopathy and long-term prognosis.

            Tako-Tsubo cardiomyopathy (TTC) is a reversible cardiomyopathy with a clinical presentation indistinguishable from myocardial infarction. TTC is estimated to represent 1%-2% of patients presenting with acute myocardial infarction. It most commonly occurs in postmenopausal women and is frequently precipitated by a stressful event. Chest pain and dyspnea are the typical presenting symptoms. Transient ST-segment elevation on ECG and a small rise in cardiac biomarkers are common. Characteristic wall motion abnormalities extend beyond the territory of a single epicardial coronary artery in the absence of obstructive coronary lesions. Supportive treatment leads to spontaneous rapid recovery in nearly all patients. The prognosis is excellent, and recurrence occurs in < 10% of patients. In this article, we review the clinical features of TTC that form the basis of the Mayo Clinic diagnostic criteria, as well as the long-term prognosis for this type of cardiomyopathy.
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              Reverse or inverted takotsubo cardiomyopathy (reverse left ventricular apical ballooning syndrome) presents at a younger age compared with the mid or apical variant and is always associated with triggering stress.

              Takotsubo cardiomyopathy is usually caused by triggering stress. It has 4 different subtypes. There has been no consensus to differentiate various types with regard to characteristics of the patient population. The goal of this study was to evaluate any clinical differences between the reverse type in comparison to common apical and mid-cavitary types using case series of reported cases. The authors searched published articles in PubMed and Medline on takotsubo or stress-induced cardiomyopathy. They included only cases that reported different types of takotsubo cardiomyopathy with baseline clinical characteristics. They identified 60 patients for the final analysis. The types of takotsubo cardiomyopathy seen in this study are classified as classic (66.7%), mid-cavitary (10%), or reverse (inverted) (23.3%). Patients with reverse-type takotsubo cardiomyopathy were significantly younger compared with those with other types (mean age, 36 for reverse vs 62 for other types; P<.001). Furthermore, all patients with the reverse type had physical or mental stress, whereas those with other types had no triggering stress in 02% of the reported cases (P<.0001). Among patients presenting with takotsubo cardiomyopathy, the reverse or inverted variant presents at a younger age and is always associated with a triggering of emotional or physical stress. © 2010 Wiley Periodicals, Inc.
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                Author and article information

                Journal
                CRD
                Cardiology
                10.1159/issn.0008-6312
                Cardiology
                S. Karger AG
                0008-6312
                1421-9751
                2014
                November 2014
                29 October 2014
                : 129
                : 4
                : 213-215
                Affiliations
                aDivision of Cardiovascular Medicine and bDepartment of Internal Medicine, University of Toledo, Toledo, Ohio, USA
                Author notes
                *Pradeep Krishna Bhat, MD, Division of Cardiovascular Medicine, University of Toledo, 3000 Arlington Avenue,, Toledo, OH 43614 (USA), E-Mail Pradeepkbhat@yahoo.com
                Article
                365963 Cardiology 2014;129:213-215
                10.1159/000365963
                25359563
                © 2014 S. Karger AG, Basel

                Copyright: All rights reserved. No part of this publication may be translated into other languages, reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, microcopying, or by any information storage and retrieval system, without permission in writing from the publisher. Drug Dosage: The authors and the publisher have exerted every effort to ensure that drug selection and dosage set forth in this text are in accord with current recommendations and practice at the time of publication. However, in view of ongoing research, changes in government regulations, and the constant flow of information relating to drug therapy and drug reactions, the reader is urged to check the package insert for each drug for any changes in indications and dosage and for added warnings and precautions. This is particularly important when the recommended agent is a new and/or infrequently employed drug. Disclaimer: The statements, opinions and data contained in this publication are solely those of the individual authors and contributors and not of the publishers and the editor(s). The appearance of advertisements or/and product references in the publication is not a warranty, endorsement, or approval of the products or services advertised or of their effectiveness, quality or safety. The publisher and the editor(s) disclaim responsibility for any injury to persons or property resulting from any ideas, methods, instructions or products referred to in the content or advertisements.

                Page count
                Figures: 2, Pages: 3
                Categories
                Novel Insights from Clinical Experience

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