Dynamic Left Intraventricular Obstruction Phenotype in Takotsubo Syndrome

Abstract

Takotsubo syndrome (TTS) is characterized by acute, generally transient left ventricular (LV) dysfunction. Although TTS has been long regarded as a benign condition, recent evidence showed that rate of acute complications and in-hospital mortality is comparable to that of patients with acute coronary syndrome. In particular, the prevalence of cardiogenic shock ranges between 6% and 20%. In this setting, detection of mechanisms leading to cardiogenic shock can be challenging. Besides a severely impaired systolic function, onset of LV outflow tract obstruction (LVOTO) together with mitral regurgitation related to systolic anterior motion of mitral valve leaflets can lead to hemodynamic instability. Early identification of LVOTO with echocardiography is crucial and has important implications on selection of the appropriate therapy. Application of short-acting b1-selective betablockers and prudent administration of fluids might help to resolve LVOTO. Conversely, inotrope agents may increase basal hypercontractility and worsen the intraventricular pressure gradient. To date, outcomes and management of patients with TTS complicated by LVOTO as yet has not been comprehensively investigated.

Keywords: Takotsubo syndrome; cardiogenic shock; echocardiography; heart failure; left ventricular outflow tract obstruction.

Figure 1

Apical 4-chamber view: in telediastole (A), in telesystole (B) showing apical ballooning (see arrows) in TTS on day 1; in telediastole (C), in telesystole (D) showing normal apical contractility on day 6. Left ventriculography (RAO 30°) in telediastole (E), in telesystole (F) on day 1 showing apical ballooning and hypercontractility of basal segments resembling typical Japanese octopus pot. RAO: right anterior oblique.

Figure 2

Panel (A) TTE with zoom on left ventricle outflow tract showing systolic anterior movement of anterior mitral leaflet during systole (see arrow); (B) Color M-Mode showing strong blood acceleration through left ventricle outflow tract in telesystole (see arrow); (C) CW-Doppler at TTE showing intraventricular peak gradient of 63 mmHg (see arrow); (D) TTE with zoom on left ventricle outflow tract showing absence of systolic anterior movement of anterior mitral leaflet during systole at recovery on day 6; (E) Color M-Mode showing regular blood acceleration through left ventricle outflow tract in telesystole at recovery; (F) CW-Doppler at TTE showing resolution of intraventricular gradient at recovery in the same patient. TTE: transthoracic echocardiography; CW: continuous wave.

Figure 3

Management of patients with Takotsubo syndrome and hypotension. LVOTO: left ventricular outflow tract obstruction; MCS: mechanical circulatory support; VA-ECMO: veno-arterial extracorporeal membrane oxygenation; IABP: intra-aortic balloon pump (or intra-aortic balloon counterpulsation). * If acute coronary syndrome has not yet been ruled out, patients should undergo coronary angiography first. Slow pullback of pigtail catheter from left ventricular (LV) cavity allows early invasive assessment of intraventricular pressure gradients and can rule out LVOTO [7]. ^# Careful fluid administration should occur in consideration of LV ejection fraction and only in absence of acute heart failure with pulmonary oedema. ^§ Ventricular thrombus and severe pulmonary congestion should be excluded, alternatively consider VA-ECMO.