Two Cases of Apical Ballooning Syndrome Masking Apical Hypertrophic Cardiomyopathy

Apical akinesis and dilation in the absence of obstructive coronary artery disease is a typical feature of stress-induced (takotsubo) cardiomyopathy, whereas apical hypertrophy is seen in apical-variant hypertrophic cardiomyopathy. We report the cases of 2 patients who presented with takotsubo cardiomyopathy and were subsequently found to have apical-variant hypertrophic cardiomyopathy, after the apical ballooning from the takotsubo cardiomyopathy had resolved. The first patient, a 43-year-old woman with a history of alcohol abuse, presented with shortness of breath, electrocardiographic and echocardiographic features consistent with takotsubo cardiomyopathy, and no significant coronary artery disease. An echocardiogram 2 weeks later revealed a normal left ventricular ejection fraction and newly apparent apical hypertrophy. The 2nd patient, a 70-year-old woman with pancreatitis, presented with chest pain, apical akinesis, and a left ventricular ejection fraction of 0.39, consistent with takotsubo cardiomyopathy. One month later, her left ventricular ejection fraction was normal; however, hypertrophy of the left ventricular apex was newly noted. To our knowledge, these are the first reported cases in which apical-variant hypertrophic cardiomyopathy was masked by apical ballooning from stress-induced cardiomyopathy.     

It’s a Trap! Clinical Similarities and Subtle ECG Differences between Takotsubo Cardiomyopathy and Myocardial Infarction

We describe a 65-year-old woman with a history of hypertension and smoking who presented with an acute episode of chest pain precipitated by severe emotional stress. Her initial electrocardiogram done in the emergency room showed non-specific T wave changes in the lateral leads and her cardiac troponin levels were mildly elevated. Because of her clinical presentation, she was admitted with a presumptive diagnosis of acute myocardial infarction and managed with antiplatelet and anticoagulant therapy. Coronary angiogram did not reveal coronary artery disease and left ventriculography showed findings consistent with apical ballooning syndrome or takotsubo cardiomyopathy. Subsequent electrocardiograms displayed dramatic changes including T wave inversions, QT interval prolongation and U waves. The patient remained asymptomatic and recovered uneventfully. Three weeks post-discharge, an echocardiogram documented resolved left ventricular dysfunction. We describe the clinical features and highlight the electrocardiographic findings that may help differentiate takotsubo cardiomyopathy from myocardial infarction.     

The pi sign as an indicator of aberrant origin of obtuse marginal coronary artery

Of 3,856 coronary angiographic studies performed by a single operator from December 2000 to March 2006, 24 (0.6%) had an aberrant origin of the obtuse marginal branch from the left anterior descending coronary artery (n = 20, 84%) or its diagonal branch (n = 2, 8%) or from the ramus intermedius coronary artery (n = 2, 8%) with an appearance mimicking the Greek letter pi. Patients were 40 to 69 years old (54 +/- 9), all were white, and 18 (75%) were men. Obstructive coronary artery disease was present in 13 (54%) and involved the aberrant obtuse marginal branch in 4 (17%). No specific pattern of symptoms, clinical presentation, or electrocardiographic finding could be attributed directly to this coronary anomaly. In conclusion, we have described a previously unreported coronary anomaly. Potential implications of this type coronary anomaly are (1) an angiographic appearance of a missing branch of the left circumflex coronary artery and (2) extensive anteroseptal, apical, and posterolateral ischemia due to proximal left anterior descending coronary artery obstruction.     

Redo off-pump coronary bypass grafting with arterial grafts for Kawasaki disease

Surgical revascularization for coronary artery lesions secondary to Kawasaki disease is relatively uncommon. The late stenosis of the saphenous vein graft is the problem to be solved. We report a case of redo off-pump coronary bypass grafting in a 35-year-old man, 20 years after bypass grafting using a saphenous vein graft. Off-pump total arterial revascularization was performed uneventfully. The procedure comprised grafting of bilateral internal thoracic arteries to left anterior descending branch and obtuse marginal branch, and radial artery to AV branch and posterior descending branch. Off-pump total arterial revascularization is a safe and less invasive procedure at the time of redo operation, even for patients with Kawasaki disease.     

Atypical takotsubo cardiomyopathy with preservation of apical contraction: a case report including pathological findings

A 60-year-old woman presented with sudden chest and back pain. Electrocardiography suggested anterior myocardial infarction but coronary angiography revealed no significant stenosis in the coronary artery. Left ventriculography revealed akinesis of the mid ventricle and preserved contraction of the apical wall. The clinical condition of atypical left ventricular akinesia was suggested to be the same as conventionally reported typical takotsubo cardiomyopathy. Repeated left ventriculography revealed the abnormal wall motion had disappeared. The findings of endomyocardial biopsy were compatible with takotsubo cardiomyopathy. Although the clinical presentation of the left ventricle is atypical, the pathological findings may be the same as typical takatsubo cardiomyopathy.     

国产雷帕霉素药物洗脱支架在冠状动脉分叉病变介入治疗中的应用

目的探讨国产雷帕霉素药物洗脱支架[DE(SFirebirdTM)]在冠状动脉分叉病变介入治疗中应用的安全性和有效性。方法对47例冠心病患者的53处冠状动脉分叉病变行介入治疗,共置入FirebirdTM68枚。结果46例介入治疗成功,失败1例。分叉病变部位:左主干远端前降支和回旋支分叉病变2处,前降支和对角支分叉病变23处,回旋支和钝缘支分叉病变17处,左心室后侧支和后降支11处。术中发生边支血管闭塞4例,边支血管狭窄加重6例,边支血管发生慢血流3例。住院期间发生急性非ST段抬高型心肌梗死3例,ST段抬高型心肌梗死1例,心绞痛5例,1例于术后2天死于心源性休克。随访6个月,7例复发心绞痛而再次住院治疗,无其余主要不良心脏事件发生。结论DE(SFirebirdTM)在冠状动脉分叉病变介入治疗中应用是可行、安全有效的。     

Fracture of a balloon on a wire device during coronary angioplasty

In a 61-year-old patient with unstable angina an attempt was made to dilate a severe stenosis in a tortuous obtuse marginal branch. The initial attempt with conventional equipment was not successful; although the wire could be advanced distal to the stenosis, a 2.0 balloon did not cross the stenosis. A second attempt with a balloon on a wire device resulted in fracture of this catheter, with the distal 2.8-cm-long fragment looped in the left coronary artery. Immediate bypass surgery was performed and the broken fragment was easily removed from the left coronary ostium. The patient made an uneventful recovery.     

Recurrent Takotsubo Cardiomyopathy Related to Recurrent Thyrotoxicosis

Takotsubo cardiomyopathy, or transient left ventricular apical ballooning syndrome, is characterized by acute left ventricular dysfunction caused by transient wall-motion abnormalities of the left ventricular apex and mid ventricle in the absence of obstructive coronary artery disease. Recurrent episodes are rare but have been reported, and several cases of takotsubo cardiomyopathy have been described in the presence of hyperthyroidism. We report the case of a 55-year-old woman who had recurrent takotsubo cardiomyopathy, documented by repeat coronary angiography and evaluations of left ventricular function, in the presence of recurrent hyperthyroidism related to Graves disease. After both episodes, the patient''s left ventricular function returned to normal when her thyroid function normalized. These findings suggest a possible role of thyroid-hormone excess in the pathophysiology of some patients who have takotsubo cardiomyopathy.     

Treatment of severe coronary artery disease with quadruple and quintuple saphenous vein grafts. Review of 100 consecutive patients.

In order to establish the anatomic criteria, the functional results, and the safety of complete myocardial revascularization for severe coronary artery disease, 100 consecutive patients who received four or five saphenous-vein grafts were analyzed. Ages ranged from 37 to 75 years (mean, 56 years). Men predominated by a ratio of 12:1. As an indication of the severity of multiple-vessel disease, 28 percent were in functional class 4, and left ventricular function was classified as good in 47 percent, as fair in 44 percent, and as poor in 8 percent. Coronary arterial scores ranged from 9 to 15 (average, 12.2). Fourteen patients had significant left main coronary arterial obstruction. All 100 patients had grafts to the left anterior descending coronary artery; 96 to the right coronary artery; 94 to the obtuse marginal branch of the circumflex; 78 to a diagonal branch of the left anterior descending; and 27 to the distal circumflex. Operative mortality was 5 percent. Nonfatal perioperative myocardial infarction occurred in 10 percent, and only one of these had low cardiac output. Follow-up from 5 to 23 months showed 95 percent of the patients to be improved, with 70 percent free of angina. Two late deaths occurred, for an overall mortality of 7 percent.     

Comparison of exercise radionuclide angiography with thallium SPECT imaging for detection of significant narrowing of the left circumflex coronary artery.

Although quantitation of exercise thallium tomograms has enhanced the noninvasive diagnosis and localization of coronary artery disease, the detection of stenosis of the left circumflex coronary artery remains suboptimal. Because posterolateral regional wall motion during exercise is well assessed by radionuclide angiography, this study determined whether regional dysfunction of the posterolateral wall during exercise radionuclide angiography is more sensitive in identifying left circumflex disease than thallium perfusion abnormalities assessed by single-photon emission computed tomography (SPECT). One hundred ten consecutive patients with CAD were studied, of whom 70 had a significant stenosis of the left circumflex coronary artery or a major obtuse marginal branch. Both regional function and segmental thallium activity of the posterolateral wall were assessed using visual and quantitative analysis. Left ventricular regional function was assessed objectively by dividing the left ventricular region of interest into 20 sectors; the 8 sectors corresponding to the posterolateral free wall were used to assess function in the left circumflex artery distribution. Similarly, using circumferential profile analysis of short-axis thallium tomograms, left ventricular myocardial activity was subdivided into 64 sectors; the 16 sectors corresponding to the posterolateral region were used to assess thallium perfusion abnormalities in the left circumflex artery territory. Qualitative posterolateral wall motion analysis detected 76% of patients with left circumflex coronary artery stenosis, with a specificity of 83%, compared with only 44% by qualitative thallium tomography (p less than 0.001) and a specificity of 92%. Whereas quantitation of thallium activity increased the sensitivity for detecting left circumflex coronary artery stenosis to 80% with a specificity of 55%, it did not achieve statistical significance when compared with qualitative wall motion analysis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Emergency rotational ablation of a calcified left main coronary artery stenosis in a patient with ischemic induced cardiogenic shock

High-speed rotational ablation is ideal in the treatment of chronic calcified atherosclerotic lesions. This report describes an elderly woman with a prior history of coronary artery bypass surgery, who developed cardiogenic shock secondary to occlusion of a saphenous vein graft to the obtuse marginal branch of the circumflex coronary artery. Her left main coronary artery was heavily calcified and almost completely occluded. She was treated successfully by high-speed rotational ablation of her left main stenosis. © 1995 Wiley-Liss, Inc.     

Diastolic segmental coronary artery obliteration in constrictive pericarditis

A patient with severe constrictive pericarditis demonstrated a new angiographic sign of segmental diastolic obliteration of an obtuse marginal branch of the circumflex system of the left coronary artery.     

An angiographic and intravascular ultrasound study of the left anterior descending coronary artery in takotsubo cardiomyopathy

The precise cause of takotsubo cardiomyopathy (TC) remains controversial. Plaque rupture with transient thrombotic occlusion of a transapical left anterior descending coronary artery (LAD) has been advanced as a potential mechanism. To explore this hypothesis, the investigators analyzed data from 11 patients prospectively enrolled in the Rhode Island Takotsubo Cardiomyopathy Registry who underwent coronary angiography and intravascular ultrasound evaluation of the LAD during their initial presentation. Despite the presence of nonobstructive coronary artery disease, no culprit lesion was identified in any patient. Similarly, the course of the LAD failed to account for the characteristic left ventricular apical ballooning seen in TC. In conclusion, an atherosclerotic coronary lesion in the LAD causing an aborted myocardial infarction may not be the primary underlying cause of TC, and nonobstructive coronary artery disease and TC may coexist without a direct causal association.     

Takotsubo cardiomyopathy, or broken-heart syndrome

Takotsubo cardiomyopathy mimics acute coronary syndrome and is accompanied by reversible left ventricular apical ballooning in the absence of angiographically significant coronary artery stenosis. In Japanese, "takotsubo" means "fishing pot for trapping octopus," and the left ventricle of a patient diagnosed with this condition resembles that shape. Takotsubo cardiomyopathy, which is transient and typically precipitated by acute emotional stress, is also known as "stress cardiomyopathy" or "broken-heart syndrome."Herein, we describe the clinical angiographic characteristics of 4 patients who exhibited this syndrome, and we review the existing literature and propose reasons to conduct prospective studies.     

单纯药物涂层球囊策略治疗冠状动脉分叉病变分支血管的临床观察

目的观察单纯应用药物涂层球囊治疗冠状动脉分叉病变的安全性及有效性。方法入选我院心内科31例分叉病变患者(主支狭窄50%,分支开口狭窄70%;分支血管参考直径≥2mm),单纯应用药物涂层球囊处理分支血管,观察手术成功率、分支血管血流情况及并发症发生率,术后9个月行冠状动脉造影检查,记录随访过程中不良心血管事件(MACE)的发生情况。结果 31例患者33个分叉病变中位于前降支/对角支占57.58%,回旋支/钝缘支占30.30%,右冠状动脉/后降支或左室后支占12.12%。31例患者均成功完成分叉病变介入治疗,手术成功率100%,并且全部患者均经桡动脉途径完成。其中2列患者出现分支血管夹层(1例TIMI血流2级)进行补救性药物洗脱支架植入。围手术期及术后临床随访(门诊或电话随访),无死亡或心肌梗死等主要心脏不良事件发生。74.19%的患者完成了冠状动脉造影复查,仅1例行靶病变再次血运重建(TLR)。分支晚期管腔丢失(LLL)为(0.13±0.25)mm。结论单独药物涂层球囊策略处理冠状动脉分叉病变分支血管是安全有效的。     

Inverted takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a transient acute left ventricular dysfunction characterized by left ventricular apical akinesis and ballooning without obstructive coronary disease described predominantly in post-menopausal women in the setting of acute emotional or physical stress. Recent reports have described isolated transient basal akinesis (inverted takotsubo cardiomyopathy) in mostly female patients with acute neurologic disorders or pheochromocytoma. We describe a rare case of a 78-year-old male with inverted takotsubo cardiomyopathy in the setting of acute abdominal pain attributed to biliary colic. A review of published literature reveals that inverted takotsubo cardiomyopathy precipitated by acute stress rather than an acute neurologic disorder appears to be an extremely rare presentation in a male patient. We discuss the relevant literature regarding incidence and reported gender distribution of inverted takotsubo cardiomyopathy.     

Effect of programmed ventricular stimulation on myocardial lactate extraction in patients with and without coronary artery disease

The arterial-coronary sinus lactate difference was measured in 17 patients after each step of a programmed ventricular stimulation protocol consisting of single, double, and triple extrastimuli, first at a basic drive cycle length of 600 msec, then at 400 msec, with an inter-train interval of 4 seconds. Four patients had no structural heart disease, four had an idiopathic dilated cardiomyopathy, and nine had coronary artery disease with a significant stenosis in at least one branch of the left coronary artery. Net myocardial lactate production during programmed ventricular stimulation was observed in three patients with coronary artery disease, but not in any patient without coronary artery disease. Among the patients who had coronary artery disease, net myocardial lactate production generally occurred in the patients who had more severe coronary artery disease. Exercise-induced ischemia, as demonstrated by a stress thallium-201 test, did not correlate with myocardial lactate production during programmed ventricular stimulation. Programmed ventricular stimulation, with a stimulation protocol typically used in many electrophysiology laboratories, is capable of inducing myocardial ischemia in at least some patients who have coronary artery disease. This finding suggests that myocardial ischemia may potentially influence the results of programmed ventricular stimulation in some patients with coronary artery disease.     

Coronary Embolization from a Left Atrial Myxoma Containing Malignant Lymphoma Cells

Systemic embolization from a primary cardiac tumor is a relatively frequent presentation. However, an acute myocardial infarction due to coronary embolization is rarely seen. We offer an unusual case of a 50-year-old man who presented with severe angina and was diagnosed with an inferolateral ST-segment-elevation myocardial infarction. Aside from otherwise healthy coronary arteries, his coronary angiogram revealed an acute occlusion of the first obtuse marginal branch, which was treated with balloon angioplasty. Because no residual plaque or dissection was found after the angioplasty, an embolic source was suspected. An echocardiogram then revealed a large mobile left atrial myxoma prolapsing into the left ventricle, so the patient underwent minimally invasive resection. Detailed pathologic examination of the myxoma revealed a concomitant high-grade B-cell lymphoma.     

Axial plaque redistribution after coronary stent deployment

We report a case of axial plaque redistribution after coronary stent deployment assessed by intravascular ultrasound (IVUS) as well as coronary angiography. A 72-year-old male with a history of hypertension, hyperlipidemia and a nuclear stress test demonstrating anterior and lateral ischemia was admitted for cardiac catheterization. Coronary angiography and IVUS examination revealed eccentric stenoses in the left anterior descending artery (LAD) and the left circumflex artery (LCx), just before the bifurcation of the first obtuse marginal branch. After successful LAD stent placement, the LCx was also stented, jailing the obtuse marginal branch. Immediately after dilatation, however, the coronary angiogram showed a new significant stenosis at the distal adjacent segment. IVUS examination after administration of nitroglycerin revealed a secondary critical lesion that was not observed before the interventional procedure. A significant plaque increase at the new lesion site presumably resulted from axial plaque redistribution (extrusion from the stented segment, otherwise known as plaque shift). After additional stenting, the patient had an uneventful course.     

The role of carotid atherosclerosis in the distinction between ischaemic and non-ischaemic cardiomyopathy.

AIM: Sometimes ischaemic cardiomyopathy is a result of severe coronary artery disease of an occult course, without typical symptoms or evidence of myocardial infarction. This form of presentation is usually indistinguishable from non-ischaemic dilated cardiomyopathy. Carotid bifurcation atherosclerosis and coronary artery disease have been shown to be strongly associated. We prospectively examined the value of extracranial carotid atherosclerosis in the distinction between ischaemic and non-ischaemic aetiology in patients with clinically unexplained cardiomyopathy. METHODS AND RESULTS: Seventy-eight patients with undetermined dilatation and diffuse impairment of the left ventricular contraction were studied within 28 months. They underwent carotid scan and coronary arteriography. Carotid atherosclerosis was found to be very common in ischaemic and rare in non-ischaemic cardiomyopathy. The presence of at least one abnormal carotid finding (intima-media thickness >1 mm, plaques, severe carotid stenosis) was 96% sensitive and 89% specific for ischaemic cardiomyopathy. CONCLUSION: Carotid scanning may be a useful screening and decision making tool in patients with cardiomyopathy of indecisive cause. Patients with carotid atherosclerosis are likely to suffer from severe coronary artery disease. Coronary angiography and subsequent myocardial viability studies, when indicated, could be considered early during their evaluation. In contrast, a negative carotid scan predicts non-ischaemic cardiomyopathy.