Left Ventricular Thrombi and Embolic Events in Takotsubo Syndrome despite Therapeutic Anticoagulation

Introduction: Takotsubo syndrome (TTS) may be complicated by left-ventricular (LV) thrombus formation in 1.3–5.3% of patients. Risk factors for thrombi comprise apical TTS, elevated levels of C-reactive protein and troponine, thrombocytosis, persisting ST segment elevation and right-ventricular involvement. Embolic risk appears high, and anticoagulation is recommended. Case Presentation: We present 3 females, aged 60–82 years, with TTS-associated LV thrombi and cerebral embolism despite therapeutic anticoagulation. Two patients showed apical and 1 patient midventricular ballooning. In 2 patients LV thrombi had not been present at the first echocardiographic examination. LV thrombi were multiple and highly mobile in 2 patients; 1 patient had a single immobile thrombus associated with spontaneous echocardiographic contrast (SEC). In each case, 3 of the described risk factors for LV thrombus formation were identified. The embolic stroke occurred 41–120 h after TTS symptom onset and 21–93 h after the initiation of therapeutic anticoagulation. Two patients were discharged with a neurological deficit, and 1 of them eventually died as a consequence of the stroke. LV thrombectomy to prevent embolism, which has been reported in a small number of cases, had not been considered in our patients. Conclusion: At present, the management of patients with TTS-related thrombi is still unclear, and further studies are urgently needed to assess the best methods for imaging and anticoagulation and to determine the role of thrombolysis and cardiac surgery. Until these studies are available, we suggest the following approach: patients with a TTS-related thrombus should be monitored by echocardiography while receiving anticoagulation. In case of highly mobile LV thrombi, the heart team may consider cardiac surgery to prevent systemic embolism. The role of SEC in TTS remains to be determined.

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Risk factors for Takotsubo Syndrome Following Cardiac Surgery: A Case–Control Study

10.21203/rs.3.rs-131034/v1 ◽

2020 ◽

Author(s):

Yun Seok Kim ◽

Ju Yong Lim

Keyword(s):

Risk Factors ◽

Cardiac Surgery ◽

Cardiopulmonary Bypass ◽

Protective Factor ◽

Ventricular Outflow Tract ◽

Mitral Valve Surgery ◽

Left Ventricular ◽

Valve Surgery ◽

Control Group ◽

Takotsubo Syndrome

Abstract Background: Takotsubo syndrome following cardiac surgery is a rare occurrence. However, early diagnosis is essential to prevent treatment which could increase the left ventricular outflow tract pressure gradient in patients with Takotsubo syndrome, and lead to cardiogenic shock. Therefore, our study aimed to identify the incidence of Takotsubo syndrome after cardiopulmonary bypass and the associated risk factors and prognosis.Methods: We retrospectively studied 5,773 patients who underwent cardiopulmonary bypass between February 2007 and July 2017. Among these, Takotsubo syndrome was diagnosed in 52 (0.9%). To evaluate the risk factors for Takotsubo syndrome, 104 of the remaining 5,721 patient were randomly selected as the control group (1:2 ratio). Univariate and multivariate logistic regression analyses were used for risk factor analysis. Results: Majority of patients (69.2%) in the Takotsubo syndrome group underwent mitral valve surgery, compared to 32.7% in the control group. The following risk factors of Takotsubo syndrome were identified: atrio-ventricular valve surgery (odds ratio (OR),10.5; 95% confidence interval (CI), 2.6-42.5; P=0.001); and the immediate postoperative use of epinephrine (OR, 3.3; 95%CI, 1.0-10.7; P=0.05) and dobutamine (OR, 4.8; 95%CI, 1.72-13.3; P=0.003). Hypertension was a significant protective factor against Takotsubo syndrome following cardiac surgery (OR, 0.22; 95%CI, 0.06-0.73; P=0.01).Conclusions: Takotsubo syndrome following cardiac surgery is rare. Immediate postoperative use of epinephrine and doputamine, as well as atrio-ventricular valve surgery were factors associated with the development of Takotsubo syndrome.

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Risk factors for stroke after cardiac surgery: The role of screening carotid ultrasonography

The Thoracic and Cardiovascular Surgeon ◽

10.1055/s-0031-1297441 ◽

2012 ◽

Vol 60 (S 01) ◽

Author(s):

U Boeken ◽

P Akhyari ◽

JP Minol ◽

A Assmann ◽

A Lichtenberg

Keyword(s):

Risk Factors ◽

Cardiac Surgery ◽

Carotid Ultrasonography

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The role of cardiac surgery in transvenous lead extraction (TLE) – experience from high volume center and 3207 procedures

European Heart Journal ◽

10.1093/ehjci/ehaa946.0836 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

L Tulecki ◽

M Czajkowski ◽

S Targonska ◽

K Tomkow ◽

D Nowosielecka ◽

...

Keyword(s):

Cardiac Surgery ◽

Tricuspid Valve ◽

Surgical Intervention ◽

Clinical Success ◽

Left Ventricular ◽

Lead Extraction ◽

Icd Leads ◽

Ventricular Lead ◽

Cardiac Surgeon

Abstract Background The guidelines suggest close co-operation between TLE operating team and cardiac surgery and its key role in the management of life-threatening complications remains unquestionable. But the role of cardiac surgeon seems to be much more extended. Purpose We have analysed the role of cardiac surgery in treatment of patients undergoing TLE procedures. Methods Using standard non-powered mechanical systems we have extracted ingrown PM/ICD leads from 3207 pts (38,7% female, average age 65,7-y) during the last 14 years. Non-infectious TLE indications were in 66,4% of patients. 46% had PM DDD system, 19% PM SSI, 22% ICD, 9% CRT, 4% other systems. In 12% of patients abandoned leads were found. 8% of patients had one lead, 54% - two, 15% - three and 4% - 4–6 leads in the heart. An average dwell time of all leads was 91,5 mth. The lead entry side was left in 96% of patients, right in 3% and both – 4%. Results Procedural success 96,1%, clinical success - 97,8%, procedure-related death 0,2%. Major complications appeared in 1,9% (cardiac tamponade 1,2%, haemothorax 0,2%, tricuspid valve damage 0,3%, stroke, pulmonary embolism <1%). Conclusions Rescue cardiac surgery (for severe haemorrhagic complications) is still the most frequent reason of surgical intervention (1,1%). The second area of co-operation includes supplementary cardiac surgery after (incomplete) TLE (0,8%). The third one is connected with reconstruction or replacement of tricuspid valve, which can be affected by ingrown lead or damaged during TLE procedure (0,5%). Implantation of the complete epicardial system during any surgical intervention (rescue or delayed) should be considered as a supplementation of the operation (0,65%). Some of patients after TLE need implantation of epicardial leads for permanent epicardial pacing (0,6%) and some only left ventricular lead to rebuild permanent cardiac resynchronisation (0,5%). The single experience of large TLE centre indicates the necessity of close co-operation with cardiac surgeon, whose role seems to be more comprehensive than a surgical stand-by itself. Table 1 Funding Acknowledgement Type of funding source: None

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Cardiac Rupture—The Most Serious Complication of Takotsubo Syndrome: A Series of Five Cases and a Systematic Review

Journal of Clinical Medicine ◽

10.3390/jcm10051066 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1066

Author(s):

Małgorzata Zalewska-Adamiec ◽

Hanna Bachórzewska-Gajewska ◽

Sławomir Dobrzycki

Keyword(s):

Female Gender ◽

Left Ventricular ◽

Cardiac Rupture ◽

Control Group ◽

Mechanical Complication ◽

Takotsubo Syndrome ◽

St Segment Elevation ◽

Glucose Levels ◽

Risk Of Death ◽

St Segment

Background: The most serious complication of the acute Takotsubo phase is a myocardial perforation, which is rare, but it usually results in the death of the patient. Methods: In the years 2008–2020, 265 patients were added to the Podlasie Takotsubo Registry. Cardiac rupture was observed in five patients (1.89%), referred to as the Takotsubo syndrome with complications of cardiac rupture (TS+CR) group. The control group consisted of 50 consecutive patients with uncomplicated TS. The diagnosis of TS was based on the Mayo Clinic Criteria. Results: Cardiac rupture was observed in women with TS aged 74–88 years. Patients with TS and CR were older (82.20 vs. 64.84; p = 0.011), than the control group, and had higher troponin, creatine kinase, aspartate aminotransferase, and blood glucose levels (168.40 vs. 120.67; p = 0.010). The TS+CR group demonstrated a higher heart rate (95.75 vs. 68.38; p < 0.0001) and the Global Registry of Acute Coronary Events (GRACE) scores (186.20 vs. 121.24; p < 0.0001) than the control group. In patients with CR, ST segment elevation was recorded significantly more often in the III, V4, V5 and V6 leads. Left ventricular free wall rupture was noted in four patients, and in one case, rupture of the ventricular septum. In a multivariate logistic regression, the factors that increase the risk of CR in TS were high GRACE scores, and the presence of ST segment elevation in lead III. Conclusions: Cardiac rupture in TS is rare but is the most severe mechanical complication and is associated with a very high risk of death. The main risk factors for left ventricular perforation are female gender, older age, a higher concentration of cardiac enzymes, higher GRACE scores, and ST elevations shown using electrocardiogram (ECG).

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Analysis of risk factors for different subtypes of acute coronary syndrome

Journal of International Medical Research ◽

10.1177/03000605211008326 ◽

2021 ◽

Vol 49 (5) ◽

pp. 030006052110083

Author(s):

Lei Zhang ◽

Juledezi Hailati ◽

Xiaoyun Ma ◽

Jiangping Liu ◽

Zhiqiang Liu ◽

...

Keyword(s):

Risk Factors ◽

Myocardial Infarction ◽

Acute Coronary Syndrome ◽

Brain Natriuretic Peptide ◽

Left Ventricular ◽

St Segment Elevation ◽

Amino Terminal ◽

Coronary Syndrome ◽

Segment Elevation Myocardial Infarction ◽

St Segment

Aims To investigate the different risk factors among different subtypes of patients with acute coronary syndrome (ACS). Methods A total of 296 patients who had ACS were retrospectively enrolled. Blood and echocardiographic indices were assessed within 24 hours after admission. Differences in risk factors and Gensini scores of coronary lesions among three groups were analyzed. Results Univariate analysis of risk factors for ACS subtypes showed that age, and levels of fasting plasma glucose, amino-terminal pro-brain natriuretic peptide, and creatine kinase isoenzyme were significantly higher in patients with non-ST-segment elevation myocardial infarction (NSTEMI) than in those with unstable angina pectoris (UAP). Logistic multivariate regression analysis showed that amino-terminal pro-brain natriuretic peptide and the left ventricular ejection fraction (LVEF) were related to ACS subtypes. The left ventricular end-diastolic diameter was an independent risk factor for UAP and ST-segment elevation myocardial infarction (STEMI) subtypes. The severity of coronary stenosis was significantly higher in NSTEMI and STEMI than in UAP. Gensini scores in the STEMI group were positively correlated with D-dimer levels (r = 0.429) and negatively correlated with the LVEF (r = −0.602). Conclusion Different subtypes of ACS have different risk factors. Our findings may have important guiding significance for ACS subtype risk assessment and clinical treatment.

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Is there a link between glucose levels and heart failure? An update

Arquivos Brasileiros de Endocrinologia & Metabologia ◽

10.1590/s0004-27302010000500010 ◽

2010 ◽

Vol 54 (5) ◽

pp. 488-497 ◽

Cited By ~ 6

Author(s):

Arnaldo Schainberg ◽

Antônio Ribeiro-Oliveira Jr. ◽

José Marcio Ribeiro

Keyword(s):

Risk Factors ◽

Heart Failure ◽

Epidemiological Studies ◽

Left Ventricular ◽

Glucose Levels ◽

Factors Analysis ◽

History Of ◽

Cv Disease ◽

The Relationship

It has been well documented that there is an increased prevalence of standard cardiovascular (CV) risk factors in association with diabetes and with diabetes-related abnormalities. Hyperglycemia, in particular, also plays an important role. Heart failure (HF) has become a frequent manifestation of cardiovascular disease (CVD) among individuals with diabetes mellitus. Epidemiological studies suggest that the effect of hyperglycemia on HF risk is independent of other known risk factors. Analysis of datasets from populations including individuals with dysglycemia suggests the pathogenic role of hyperglycemia on left ventricular function and on the natural history of HF. Despite substantial epidemiological evidence of the relationship between diabetes and HF, data from available interventional trials assessing the effect of a glucose-lowering strategy on CV outcomes are limited. To provide some insight into these issues, we describe in this review the recent important data to understand the natural course of CV disease in diabetic individuals and the role of hyperglycemia at different times in the progression of HF.

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Takotsubo Syndrome: Contemporary Views on the Pathogenesis, Prevalence and Prognosis

Rational Pharmacotherapy in Cardiology ◽

10.20996/1819-6446-2018-14-4-598-604 ◽

2018 ◽

Vol 14 (4) ◽

pp. 598-604 ◽

Cited By ~ 1

Author(s):

A. S. Shilova ◽

A. O. Shmotkina ◽

A. A. Yafarova ◽

M. Yu. Gilyarov

Keyword(s):

Genetic Predisposition ◽

Randomized Clinical Trials ◽

Myocardial Dysfunction ◽

Specific Treatment ◽

Left Ventricular ◽

Takotsubo Syndrome ◽

St Segment Elevation ◽

Coronary Syndrome ◽

St Segment ◽

Reversible Left Ventricular Dysfunction

Takotsubo syndrome (TTS) is a reversible left ventricular dysfunction characterized by local apical hypokinesia usually triggered by a physical or emotional stress. According to the last available data TTS may represent 2% of all admissions for acute coronary syndromes. Despite the reliable prevalence, diagnosis of TTS remains difficult. The initial presentation, both clinically and electrocardiographically, is similar to an acute myocardial infarction (AMI). The biomarker profile is also similar, although the peaks of troponin and creatinine kinase levels are lower, and brain natriuretic peptide levels are higher in patients with TTS compared with ST-segment elevation AMI. Modified Mayo diagnostic criteria are the most common for the diagnosis. Pathogenesis of TTS currently is not well understood. Catecholamines appear to play a central role in the pathophysiology of TTS. However, it is conceivable that some people have a genetic predisposition to stress-induced TTS. A genetic predisposition has been suggested based on the few familial TTS cases described. Despite reversible myocardial dysfunction, acute heart failure is the most common complication in the acute phase of TTS. In-hospital mortality rate is comparable to that of ST-segment elevation AMI. There are no randomized clinical trials to support specific treatment recommendations in TTS. It is believed that the tactics of managing patients with TTS hospitalized with suspicion of acute coronary syndrome should comply with the protocol of management of patients with AMI while acute coronary pathology is not excluded.

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Novel role of platelet reactivity in adverse left ventricular remodelling after ST-segment elevation myocardial infarction: The REMODELING Trial

Thrombosis and Haemostasis ◽

10.1160/th16-10-0744 ◽

2017 ◽

Vol 117 (05) ◽

pp. 911-922 ◽

Cited By ~ 4

Author(s):

Yongwhi Park ◽

Udaya Tantry ◽

Jin-Sin Koh ◽

Jong-Hwa Ahn ◽

Min Kang ◽

...

Keyword(s):

Myocardial Infarction ◽

Platelet Reactivity ◽

Left Ventricular ◽

Ventricular Remodelling ◽

Left Ventricular Remodelling ◽

St Segment Elevation ◽

Segment Elevation Myocardial Infarction ◽

St Segment ◽

Hs Crp

SummaryThe role of platelet-leukocyte interaction in the infarct myocardium still remains unveiled. We aimed to determine the linkage of platelet activation to post-infarct left ventricular remodelling (LVR) process. REMODELING was a prospective, observational, cohort trial including patients (n = 150) with ST-segment elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention. Patients were given aspirin plus clopidogrel therapy (600 mg loading and 75 mg daily). Platelet reactivity (PRU: P2Y12 Reaction Units) was assessed with VerifyNow P2Y12 assay on admission. Transthoracic echocardiography was performed on admission and at one-month follow-up. The primary endpoint was the incidence of LVR according to PRU-based quartile distribution. LVR was defined as a relative ≥ 20 % increase in LV end-diastolic volume (LVEDV) between measurements. Adverse LVR was observed in 36 patients (24.0 %). According to PRU quartile, LVR rate was 10.8 % in the first, 23.1 % in the second, 27.0 % in the third, and 35.1 % in the fourth (p = 0.015): the optimal cut-off of PRU was ≥ 248 (area under curve: 0.643; 95 % confidence interval: 0.543 to 0.744; p = 0.010). LVR rate also increased proportionally according to the level of high sensitivity-C reactive protein (hs-CRP) (p = 0.012). In multivariate analysis, the combination of PRU (≥ 248) and hs-CRP (≥ 1.4 mg/l) significantly increased the predictive value for LVR occurrence by about 21-fold. In conclusion, enhanced levels of platelet activation and inflammation determined the incidence of adverse LVR after STEMI. Combining the measurements of these risk factors increased risk discrimination of LVR. The role of intensified antiplatelet or anti-inflammatory therapy in post-infarct LVR process deserves further study.

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