European Journal of Echocardiography Advance Access published online on April 4, 2008
European Journal of Echocardiography, doi:10.1093/ejechocard/jen135
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2008. For permissions please email: journals.permissions@oxfordjournals.org
Tako-Tsubo syndrome in a pregnant woman
Nicola D’Amato1,*,
Paolo Colonna2,
Paolino Brindicci1,
Maria Grazia Campagna1,
Claudio Petrillo3,
Aldo Cafarelli3 and
Carlo D’Agostino1
1 Cardiology Department, Di Venere Hospital, Bari, Italy
2 Cardiology Department, Policlinico Hospital, Bari, Italy
3 Intensive Care Unit, Di Venere Hospital, Bari, Italy
Received 31 December 2007; .
* Corresponding author. Tel: +39 03295322425.E-mail address: d.amato{at}tin.it
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Abstract
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We describe a rare case of Tako-Tsubo syndrome which occurred
in a young woman at the beginning of pregnancy, who presented
cardiac arrest at onset. In this case, the transient left ventricular
ballooning involving both mid and apical segments, in absence
of coronary artery disease, produced a severe impairment of
cardiac function with typical echocardiographic and electrocardiographic
findings. The favourable outcome, despite the sudden cardiac
death at the beginning, raises further questions on this new
kind of cardiomyopathy.
Keywords: Tako-Tsubo Syndrome; Pregnancy; Sudden cardiac death; Echocardiography
Tako-Tsubo Syndrome (TTS),
1 apical ballooning syndrome,
2–3 or stress cardiomyopathy
4 are now frequently reported in international
scientific literature to describe an example of transient stunned
myocardium which tends to appears, with some exception, in post-menopausal
women, soon after a psychic and/or physic stress. This condition
lasts for a few days, sometimes recurs, and generally has a
good prognosis.
5,6
We report the case of a 32 years old woman in her fifth week of pregnancy. Her history cites a spontaneous pneumothorax 10 years earlier and some episodes of not specific tachycardia. Normal heart dimensions and function (Ejection Fraction EF = 71%) and an interatrial septum aneurysm were observed in an echocardiogram (ECHO) performed 3 years before. In the few days before she felt stressed (because of family quarrels and with the fear that her job in the radionuclide field could damage the foetus) very tired and had stomachache. Her morning sleep was interrupted by a sudden cardio-respiratory arrest, and she was immediately assisted by her husband, a trained nurse. A few minutes later the ventricular fibrillation (VF) was cardioverted to sinus rhythm with 2 DC shocks, and shortly after a second ventricular tachycardia promptly degenerated to VF was treated with 3 DC shocks (Figure 1). ABLS maneuvers and step-by-step adrenaline was performed accordingly to guidelines. Total time from the first VF to the stable sinus rhythm was 25 min.
In the intensive care unit, she suffered hypotension and diuresis
reduction, without significant electrocardiographic (ECG) anomalies
(
Figure 2A), improved after iv injection of amine (continuous
infusion of dobutamine at 6
/kg/min), plasma expander and levosimendan
(at 0.08
/kg/min). After intubation, the blood gas analysis
showed normal values.
Lung perfusion scintigraphy, coronary (
Figure 3A and
B), aortic,
and pulmonary angiography were normal the first day, while anterior
and apical left ventricular (LV) wall motion dysfunction was
observed at left ventriculography.
LV dysfunction typical of TTS was evident at an ECHO performed
24 h later by portable machine (Esaote, My Lab 25, Firenze,
Italy). All mid-apical segments of a not dilated LV were akinetic
(the 2/3 of whole LV) (Supplementary material online,
Video S1 and
2); they appeared as being separated by a short axis
plane perpendicular to the long axis (
Figure 4). The interatrial
septum aneurysm was confirmed; the mitral valve showed mild
regurgitation without evidence of systolic anterior movement;
LV outflow tract obstruction was not observed. Although medical
therapy still included amines at high dosage, EF was still depressed
(22%) and CO was only 2.1 L/m.
During the following days the patient showed a progress and on the sixth day she breathed spontaneously after extubation.
The cardiac injury enzyme markers appeared to be increased, but not proportional to the initial LV dysfunction (Figure 5). Serial ECGs evolved with a normalization of the QTc interval, which was initially prolonged (630 ms at third day. Figure 6), and with the appearance of diffuse deep negative T waves (Figure 2B). Continuous ECG monitoring did not record further ventricular arrhythmias.
Serial ECHOs documented transient LV dysfunction with EF >50% already in the ninth day, without infusion of inotropic agents. 2D strain and 2D velocity ECHO imaging proved to be feasible and to parallel the cardiac wall motion recovery, even with a more evident aspect (Figure 7A and B at third day).
We also observed the vectors of myocardial velocity and the
related curves increase with time in the mid-apical segments
of LV. Also the shape of LV returned to normal day-by-day (Supplementary
material online,
Video S3 and
4). The M-mode colour coding pictures
of Velocity-Stain per cent and SR easily documented both systolic
and diastolic functional improvement (
Figure 8A and
B on the
13th day). Unfortunately, the woman suffered a spontaneous abortion
10 days after her VF, while in the coronary care unit, but there
were no neuropsychiatric consequences after her discharge, except
for a slight depressive syndrome.
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Discussion
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We consider this TTS report as particular for the following
reasons: (i) it regards a young pregnant woman; a condition
of stress is present without an individual event (the relationship
between sexual hormones and TTS is still under investigation);
(ii) the onset was with sudden cardiac death by VF (reverted
after ABLS); (iii) it was sensitive to adrenaline; (iv) there
was no ST-segment elevation on 12 leads ECG at 1st day.
Despite the favourable outcome of this case, several aspects of this new form of cardiomyopathy have to be taken into account. Probably sudden death is not so rare in the beginning of TTS: VF can occur on the basis of a severe LV impairment, but also it is possible that arrhythmia is related to the QTc interval prolongation during the early period of disease. The restoration of cardiac function is rapid, but the real prognosis is unclear. Adrenaline therapy (or others amine) in emergency conditions can play a role in the clinical setting.
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Conclusions
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Our report of rare and atypical TTS gives new information in
understanding another aspect of this cardiomyopathy.
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Supplementary material
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Supplementary material is available at EJECHO online.
Conflict of interest: none declared.
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References
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- Sato H, Tateishi H, Uchida T, et al. Takotsubo type cardiomyopathy due to multivessel spasm. In: Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure (in Japanese).—Kodama K, Haze K, Hon M, eds. (1990) Tokyo: Kagakuhyouronsya. 56–64.
- Tsuchihashi K, Ueshima K, Uchida T, et al. Transient apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigators in Japan. J Am Coll Cardiol (2001) 38:11–8.[Abstract/Free Full Text]
- Abe Y, Kondo M, Matsuoka R, et al. Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol (2003) 41:737–42.[Abstract/Free Full Text]
- Maron BJ, Towbin JA, Thiene G. AHA Scientific Statement: Contemporary Definitions and Classification of the Cardiomyopathies. Circulation (2006) 113:1807–16.[Abstract/Free Full Text]
- 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) 50:448–52.[Abstract/Free Full Text]
- Parodi G, Del Pace S, Carrabba N, et al. Incidence, clinical findings and outcome of women with left ventricular apical ballooning syndrome. Am J Cardiol (2007) 99:182–5.[CrossRef][Web of Science][Medline]
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