689210 case-report2017
SCO0010.1177/2050313X16689210SAGE Open Medical Case ReportsKudaiberdiev et al.
SAGE Open Medical Case Reports
Case Report
Surgical treatment of left ventricular wall rupture, regarded as a consequence of Takotsubo cardiomyopathy
SAGE Open Medical Case Reports Volume 5: 1–4 © The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav https://doi.org/10.1177/2050313X16689210 DOI: 10.1177/2050313X16689210 journals.sagepub.com/home/sco
Taalaibek Kudaiberdiev, Irina Akhmedova, Gulzada Imanalieva, Ildar Abdildaev, Kilichbek Jooshev, Jamalbek Ashimov, Azamat Mirzabekov and Janibek Gaybildaev
Abstract Objective: We present the case of possible reverse type of TCM in a female patient presented with progressive left ventricular dysfunction and its rupture in pericardium. Methods: The detailed history, physical examination, laboratory tests, electrocardiography, serial echocardiography, coronary angiography with left ventriculography were performed to diagnose possible Takotsubo cardiomyopathy in 63year old woman admitted to our center with complaints of dyspnea, lightheadedness, weakness and signs of hypotension and history of inferior myocardial infarction, acute left ventricular aneurysm, and effusive pericarditis and pleuritis, developed after emotional stress 5 months ago. Results: Clinical evaluation revealed unremarkable laboratory tests, normal troponin values, signs of old inferior myocardial infarction on electrocardiogram, and left ventricular (LV) dilatation and dysfunction, akinesia of LV infero-lateral wall with thinning and its rupture and blood shunting in pericardium. Her coronary angiography revealed normal coronary arteries. The diagnosis of pheochromocytoma was excluded. The patient underwent surgery under cardiopulmonary bypass with removal of LV pseudoaneurysm. The patient was discharged from hospital with improvement in NYHA class and LV function. Conclusion: Thus, in female postmenopausal patients presenting with acute myocardial infarction signs complicated by pericarditis, intact coronary arteries and LV dysfunction with emotional stress as triggering factor, reverse type of TCM should be considered and proper management applied to prevent development of life-threatening complications like LV rupture. Keywords Takotsubo cardiomyopathy, reverse type, ventricular wall rupture, pericardium Date received: 31 May 2016; accepted: 21 December 2016
Introduction The stress cardiomyopathy or Takotsubo cardiomyopathy (TCM), described by Sato et al.,1 is a transient left ventricular (LV) apical ballooning, accompanied by LV dysfunction.2 Clinical manifestations of TCM resemble acute myocardial infarction (MI), although both may coexist,3,4 and it usually develops in postmenopausal women with intact coronary arteries. Emotional stress with sympathetic activation and catecholamine’s cardiac toxicity is the underlying mechanism in most cases, though microvascular dysfunction, coronary spasm and inflammation contribute as well.3 Usually, hypo-akinesia of apical and midventricular LV segments and hyperkinesia of basal segments are observed; however, the reverse (inverted) types were also described.1,3–7 Reverse type accounted for 23.3% of all TCM cases and emotional
stress was a leading triggering factor. The prognosis of TCM is usually benign; however, several cases of LV wall rupture were described.3–9 We present the case of reverse type of TCM in a female patient presented with progressive LV dysfunction and rupture of LV wall in pericardium.
Scientific Research Institute of Heart Surgery and Organ Transplantation, Bishkek, Kyrgyzstan Corresponding Author: Taalaibek Kudaiberdiev, Scientific Research Institute of Heart Surgery and Organ Transplantation, Bishkek 720000, Kyrgyzstan. Email: [email protected]; [email protected]
Creative Commons Non Commercial CC-BY-NC: This article is distributed under the terms of the Creative Commons AttributionNonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2
SAGE Open Medical Case Reports
Figure 1. (a) ECG shows Q wave in leads III and AVF, negative T waves DII, DIII and AVF, and ST-T abnormalities in V5-V6. 2D and Color Doppler echo images of (b) akinesia, thinning and rupture of LV infero-lateral wall; (c) LV to pericardium cross-over blood shunt through defects; and (d) massive thrombosis of cavity and inferolateral wall.
Case report A 63-year-old female patient was admitted with complaints of acute chest pain without irradiation lasting for 2 days, dyspnea, lightheadedness, weakness and signs of hypotension. She had had history of hypertension for past 10 years. She was admitted to cardiology department 5 months ago with chest pain and was treated with the diagnosis of acute inferior MI, acute LV aneurysm, New York Heart Association (NYHA) class 4 and effusive pericarditis and pleuritis. Analysis of her serial echocardiograms (echo) during previous hospitalization revealed progressive LV dilatation and dysfunction, with accumulation of pericardial fibrinous detachments and effusion during 14 days of follow-up. Her troponin values were equal to 0.0 ng/mL. In our clinic, her laboratory tests were unremarkable. ECG showed signs of old inferior wall MI and lateral wall ST-T abnormalities (Figure 1(a)). Her echo displayed LV dilatation ((left ventricular end-diastolic dimension (LVEDD), 7.6 cm; left ventricular end-systolic dimension (LVESD), 6.0 cm)), reduced left ventricular ejection fraction (LVEF, 35%), moderate mitral regurgitation, hypo-akinesia and thinning (0.6 mm) of LV infero-lateral wall with rupture and cross-over blood shunt through two defects into pericardium (Figure 1(b) and (c)) and thrombi (Figure 1(d)). Coronary angiography and left ventriculography revealed
intact coronary arteries and blood shunt from postero-basal segment into pericardium. She had no clinical or laboratory signs of pheochromocytoma, neither she had signs of myocarditis, recent cranial trauma or intracranial hemorrhage, and her echo ruled out hypertrophic cardiomyopathy. The patient underwent surgery under cardiopulmonary bypass with resection of LV pseudoaneurysm and closure of left ventricular posterior wall (LVPW) defect. During operation, we revealed pulsating mass along LV postero-diaphragmatic wall (Figure 2(a)). Cardiolysis of LVPW was applied and the mass 1.5×1.0 cm of size with dense cover was partially relieved from adhesions. Removal of dense adhesions from LVPW exposed the aneurysmal sac and defect of 1 × 1 cm communicating with LV cavity. Its cavity was filled and LV walls were covered by densely organized and epithelialized tissue (Figure 2(b) and (c)). The defect was sutured on pericardial patch; free walls of sac were dissected and removed. Microscopic analysis of samples showed thickening, sclerosis, serous-fibrinous inflammation of inner wall and nonspecific inflammation of the outer wall of pericardium. The postoperative period was stable; patient was winded off the ventilation 16 h and mobilized 36 h after surgery. Her echo after operation (Figure 2(d)) revealed reduction in LV size (LVEDD, 6.2 cm and LVESD, 4.7 cm), increase in LVEF (46%) and mild mitral regurgitation. The patient was discharged from hospital.
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Kudaiberdiev et al.
Figure 2. Intraoperative views of (a) pulsating mass 15–10 cm in size at postero-diaphragmatic wall of LV; (b, c) organized and epithelialized content of the aneurysmatic sac and LV wall; and (d) postoperative echo image of LV after resection of sac and repair of defect.
Discussion Analyzing patient’s history, we suggest the first manifestation of the disease was 5 months ago, when after emotional stress she had experienced symptoms of acute MI complicated by LV aneurysm. Furthermore, due to deterioration of LV function and progressive dilatation of aneurysm with LV rupture after another emotional stress, she was admitted to our clinic. Taking into account female sex, postmenopausal state, history, echo, catheterization and intraoperative findings, intact coronary arteries, and the development of LV aneurysmatic dilatation after emotional stress, we can consider this case as an inverted type (reverse type) of TCM during her first admission according to Mayo clinic criteria10,11 and later complicated by LV wall rupture and pericardial involvement when she was referred to our clinic for surgery. We do not exclude if she had had the inferior wall MI in the presence of intact coronary arteries.4,12 Previous cases demonstrated inverted type with akinesia of antero-lateral diaphragmal, posterior and basal midportion walls without apical ballooning,6,7 as well as myocardial rupture was described in the setting of TCM.8,9 Our case is a rare reverse type of TCM with rupture of posterior, infero-lateral walls into pericardium. Thus, in female postmenopausal patients presenting with acute MI signs complicated by pericarditis, intact coronary arteries and LV dysfunction with emotional stress as triggering factor, reverse type of TCM should be considered and
proper management applied to prevent development of life-threatening complications like LV rupture. Acknowledgements We would like to thank Prof. Gulmira Kudaiberdieva, MD, FESC, for kind assistance in preparation of case report. The patient’s written consent for publication of personal data was obtained.
Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship and/or publication of this article.
References 1. Sato H, Tateishi H, Dote K, et al. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K, Haze K and Hori M (eds) Clinical aspect of myocardial injury: from ischemia to heart failure. Tokyo, Japan: Kagakuhyoronsha Publishing Co., 1990, pp. 56–64. 2. Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional
4
3.
4.
5.
6.
SAGE Open Medical Case Reports Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation 2006; 113: 1807–1816. Kurisu S and Kihara Y. Tako-tsubo cardiomyopathy: clinical presentation and underlying mechanism. J Cardiol 2012; 60: 429–437. Parker JATC, Amerini AL, Autschbach R, et al. Takotsubo cardiomyopathy with concurrent multivessel obstructive coronary artery disease: proposition for a new clinical entity and first case surgical experience. Interact Cardiovasc Thorac Surg 2012; 14: 108–109. Ramaraj R and Movahed MR. 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. Congest Heart Fail 2010; 16: 284–286. Haghi D, Papavassiliu T, Flutcher S, et al. Variant form of the acute apical ballooning syndrome (takotsubo cardiomyopathy): observations of a novel entity. Heart 2006; 92: 392–394.
7. Bonnemeier H, Schafer U and Schunkert H. Apical ballooning without apical ballooning. Eur Heart J 2006; 27: 2246. 8. Kumar S, Kaushik S, Nautiyal A, et al. Cardiac rupture in takotsubo cardiomyopathy: a systematic review. Clin Cardiol 2011; 34: 672–676. 9. Kurisu S and Inoue I. Cardiac rupture in tako-tsubo cardiomyopathy with persistent ST-segment elevation. Int J Cardiol 2012; 158: e5–e6. 10. Prasad A, Lerman A and Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008; 155: 408–417. 11. Madhavan M and Prasad A. Proposed Mayo Clinic criteria for the diagnosis of Tako-Tsubo cardiomyopathy and long-term prognosis. Herz 2010; 35: 240–244. 12. Reynolds HR, Srichai MB, Iqbal SH, et al. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation 2011; 124: 1414–1425.
SCO0010.1177/2050313X16689210SAGE Open Medical Case ReportsKudaiberdiev et al.
SAGE Open Medical Case Reports
Case Report
Surgical treatment of left ventricular wall rupture, regarded as a consequence of Takotsubo cardiomyopathy
SAGE Open Medical Case Reports Volume 5: 1–4 © The Author(s) 2017 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav https://doi.org/10.1177/2050313X16689210 DOI: 10.1177/2050313X16689210 journals.sagepub.com/home/sco
Taalaibek Kudaiberdiev, Irina Akhmedova, Gulzada Imanalieva, Ildar Abdildaev, Kilichbek Jooshev, Jamalbek Ashimov, Azamat Mirzabekov and Janibek Gaybildaev
Abstract Objective: We present the case of possible reverse type of TCM in a female patient presented with progressive left ventricular dysfunction and its rupture in pericardium. Methods: The detailed history, physical examination, laboratory tests, electrocardiography, serial echocardiography, coronary angiography with left ventriculography were performed to diagnose possible Takotsubo cardiomyopathy in 63year old woman admitted to our center with complaints of dyspnea, lightheadedness, weakness and signs of hypotension and history of inferior myocardial infarction, acute left ventricular aneurysm, and effusive pericarditis and pleuritis, developed after emotional stress 5 months ago. Results: Clinical evaluation revealed unremarkable laboratory tests, normal troponin values, signs of old inferior myocardial infarction on electrocardiogram, and left ventricular (LV) dilatation and dysfunction, akinesia of LV infero-lateral wall with thinning and its rupture and blood shunting in pericardium. Her coronary angiography revealed normal coronary arteries. The diagnosis of pheochromocytoma was excluded. The patient underwent surgery under cardiopulmonary bypass with removal of LV pseudoaneurysm. The patient was discharged from hospital with improvement in NYHA class and LV function. Conclusion: Thus, in female postmenopausal patients presenting with acute myocardial infarction signs complicated by pericarditis, intact coronary arteries and LV dysfunction with emotional stress as triggering factor, reverse type of TCM should be considered and proper management applied to prevent development of life-threatening complications like LV rupture. Keywords Takotsubo cardiomyopathy, reverse type, ventricular wall rupture, pericardium Date received: 31 May 2016; accepted: 21 December 2016
Introduction The stress cardiomyopathy or Takotsubo cardiomyopathy (TCM), described by Sato et al.,1 is a transient left ventricular (LV) apical ballooning, accompanied by LV dysfunction.2 Clinical manifestations of TCM resemble acute myocardial infarction (MI), although both may coexist,3,4 and it usually develops in postmenopausal women with intact coronary arteries. Emotional stress with sympathetic activation and catecholamine’s cardiac toxicity is the underlying mechanism in most cases, though microvascular dysfunction, coronary spasm and inflammation contribute as well.3 Usually, hypo-akinesia of apical and midventricular LV segments and hyperkinesia of basal segments are observed; however, the reverse (inverted) types were also described.1,3–7 Reverse type accounted for 23.3% of all TCM cases and emotional
stress was a leading triggering factor. The prognosis of TCM is usually benign; however, several cases of LV wall rupture were described.3–9 We present the case of reverse type of TCM in a female patient presented with progressive LV dysfunction and rupture of LV wall in pericardium.
Scientific Research Institute of Heart Surgery and Organ Transplantation, Bishkek, Kyrgyzstan Corresponding Author: Taalaibek Kudaiberdiev, Scientific Research Institute of Heart Surgery and Organ Transplantation, Bishkek 720000, Kyrgyzstan. Email: [email protected]; [email protected]
Creative Commons Non Commercial CC-BY-NC: This article is distributed under the terms of the Creative Commons AttributionNonCommercial 3.0 License (http://www.creativecommons.org/licenses/by-nc/3.0/) which permits non-commercial use, reproduction and distribution of the work without further permission provided the original work is attributed as specified on the SAGE and Open Access pages (https://us.sagepub.com/en-us/nam/open-access-at-sage).
2
SAGE Open Medical Case Reports
Figure 1. (a) ECG shows Q wave in leads III and AVF, negative T waves DII, DIII and AVF, and ST-T abnormalities in V5-V6. 2D and Color Doppler echo images of (b) akinesia, thinning and rupture of LV infero-lateral wall; (c) LV to pericardium cross-over blood shunt through defects; and (d) massive thrombosis of cavity and inferolateral wall.
Case report A 63-year-old female patient was admitted with complaints of acute chest pain without irradiation lasting for 2 days, dyspnea, lightheadedness, weakness and signs of hypotension. She had had history of hypertension for past 10 years. She was admitted to cardiology department 5 months ago with chest pain and was treated with the diagnosis of acute inferior MI, acute LV aneurysm, New York Heart Association (NYHA) class 4 and effusive pericarditis and pleuritis. Analysis of her serial echocardiograms (echo) during previous hospitalization revealed progressive LV dilatation and dysfunction, with accumulation of pericardial fibrinous detachments and effusion during 14 days of follow-up. Her troponin values were equal to 0.0 ng/mL. In our clinic, her laboratory tests were unremarkable. ECG showed signs of old inferior wall MI and lateral wall ST-T abnormalities (Figure 1(a)). Her echo displayed LV dilatation ((left ventricular end-diastolic dimension (LVEDD), 7.6 cm; left ventricular end-systolic dimension (LVESD), 6.0 cm)), reduced left ventricular ejection fraction (LVEF, 35%), moderate mitral regurgitation, hypo-akinesia and thinning (0.6 mm) of LV infero-lateral wall with rupture and cross-over blood shunt through two defects into pericardium (Figure 1(b) and (c)) and thrombi (Figure 1(d)). Coronary angiography and left ventriculography revealed
intact coronary arteries and blood shunt from postero-basal segment into pericardium. She had no clinical or laboratory signs of pheochromocytoma, neither she had signs of myocarditis, recent cranial trauma or intracranial hemorrhage, and her echo ruled out hypertrophic cardiomyopathy. The patient underwent surgery under cardiopulmonary bypass with resection of LV pseudoaneurysm and closure of left ventricular posterior wall (LVPW) defect. During operation, we revealed pulsating mass along LV postero-diaphragmatic wall (Figure 2(a)). Cardiolysis of LVPW was applied and the mass 1.5×1.0 cm of size with dense cover was partially relieved from adhesions. Removal of dense adhesions from LVPW exposed the aneurysmal sac and defect of 1 × 1 cm communicating with LV cavity. Its cavity was filled and LV walls were covered by densely organized and epithelialized tissue (Figure 2(b) and (c)). The defect was sutured on pericardial patch; free walls of sac were dissected and removed. Microscopic analysis of samples showed thickening, sclerosis, serous-fibrinous inflammation of inner wall and nonspecific inflammation of the outer wall of pericardium. The postoperative period was stable; patient was winded off the ventilation 16 h and mobilized 36 h after surgery. Her echo after operation (Figure 2(d)) revealed reduction in LV size (LVEDD, 6.2 cm and LVESD, 4.7 cm), increase in LVEF (46%) and mild mitral regurgitation. The patient was discharged from hospital.
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Kudaiberdiev et al.
Figure 2. Intraoperative views of (a) pulsating mass 15–10 cm in size at postero-diaphragmatic wall of LV; (b, c) organized and epithelialized content of the aneurysmatic sac and LV wall; and (d) postoperative echo image of LV after resection of sac and repair of defect.
Discussion Analyzing patient’s history, we suggest the first manifestation of the disease was 5 months ago, when after emotional stress she had experienced symptoms of acute MI complicated by LV aneurysm. Furthermore, due to deterioration of LV function and progressive dilatation of aneurysm with LV rupture after another emotional stress, she was admitted to our clinic. Taking into account female sex, postmenopausal state, history, echo, catheterization and intraoperative findings, intact coronary arteries, and the development of LV aneurysmatic dilatation after emotional stress, we can consider this case as an inverted type (reverse type) of TCM during her first admission according to Mayo clinic criteria10,11 and later complicated by LV wall rupture and pericardial involvement when she was referred to our clinic for surgery. We do not exclude if she had had the inferior wall MI in the presence of intact coronary arteries.4,12 Previous cases demonstrated inverted type with akinesia of antero-lateral diaphragmal, posterior and basal midportion walls without apical ballooning,6,7 as well as myocardial rupture was described in the setting of TCM.8,9 Our case is a rare reverse type of TCM with rupture of posterior, infero-lateral walls into pericardium. Thus, in female postmenopausal patients presenting with acute MI signs complicated by pericarditis, intact coronary arteries and LV dysfunction with emotional stress as triggering factor, reverse type of TCM should be considered and
proper management applied to prevent development of life-threatening complications like LV rupture. Acknowledgements We would like to thank Prof. Gulmira Kudaiberdieva, MD, FESC, for kind assistance in preparation of case report. The patient’s written consent for publication of personal data was obtained.
Declaration of conflicting interests The author(s) declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.
Funding The author(s) received no financial support for the research, authorship and/or publication of this article.
References 1. Sato H, Tateishi H, Dote K, et al. Tako-tsubo-like left ventricular dysfunction due to multivessel coronary spasm. In: Kodama K, Haze K and Hori M (eds) Clinical aspect of myocardial injury: from ischemia to heart failure. Tokyo, Japan: Kagakuhyoronsha Publishing Co., 1990, pp. 56–64. 2. Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association Scientific Statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional
4
3.
4.
5.
6.
SAGE Open Medical Case Reports Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation 2006; 113: 1807–1816. Kurisu S and Kihara Y. Tako-tsubo cardiomyopathy: clinical presentation and underlying mechanism. J Cardiol 2012; 60: 429–437. Parker JATC, Amerini AL, Autschbach R, et al. Takotsubo cardiomyopathy with concurrent multivessel obstructive coronary artery disease: proposition for a new clinical entity and first case surgical experience. Interact Cardiovasc Thorac Surg 2012; 14: 108–109. Ramaraj R and Movahed MR. 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. Congest Heart Fail 2010; 16: 284–286. Haghi D, Papavassiliu T, Flutcher S, et al. Variant form of the acute apical ballooning syndrome (takotsubo cardiomyopathy): observations of a novel entity. Heart 2006; 92: 392–394.
7. Bonnemeier H, Schafer U and Schunkert H. Apical ballooning without apical ballooning. Eur Heart J 2006; 27: 2246. 8. Kumar S, Kaushik S, Nautiyal A, et al. Cardiac rupture in takotsubo cardiomyopathy: a systematic review. Clin Cardiol 2011; 34: 672–676. 9. Kurisu S and Inoue I. Cardiac rupture in tako-tsubo cardiomyopathy with persistent ST-segment elevation. Int J Cardiol 2012; 158: e5–e6. 10. Prasad A, Lerman A and Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008; 155: 408–417. 11. Madhavan M and Prasad A. Proposed Mayo Clinic criteria for the diagnosis of Tako-Tsubo cardiomyopathy and long-term prognosis. Herz 2010; 35: 240–244. 12. Reynolds HR, Srichai MB, Iqbal SH, et al. Mechanisms of myocardial infarction in women without angiographically obstructive coronary artery disease. Circulation 2011; 124: 1414–1425.
