Monika Budnik

Simple markers can distinguish Takotsubo cardiomyopathy from ST segment elevation myocardial infarction

BACKGROUND Takotsubo cardiomyopathy (TTC) is a clinical condition mimicking acute myocardial infarction. A specific biomarker for TTC screening is required, but until now, no single biomarker has been established for the early diagnosis of TTC and differentiation from ST-segment elevation myocardial infarction (STEMI). In our study we focused on the simple markers that are available in every hospital. METHODS In 66 consecutive patients (pts) who were hospitalized with TTC and 66 pts with STEMI, cardiac biomarkers, such as NT-proBNP, TnI, CK and CKMB mass were determined during 12h from admission and compared with demographic, clinical and echocardiographic findings. RESULTS The concentration of NTproBNP was greater in pts with TTC than STEMI (4702pg/ml vs 2138pg/ml). The concentration of TnI and CKMB mass was greater in the STEMI group than in the TTC group (TnI: 2.1ng/ml and CK MB mass: 9.5ng/ml in pts with TTC vs TnI: 19ng/ml and CK MB mass: 73.3ng/ml in pts with STEMI). The NTproBNP/TnI ratio and NTproBNP/CKMB mass ratio were, respectively, 2235.2 and 678.2 in pts with TTC and 81.6 and 27.5 in pts with STEMI (p<0.001). Moreover, the NTproBNP/EF ratio was also statistically significant (110.4 in TTC group and 39.4 in STEMI group). CONCLUSIONS NTproBNP/TnI, NTproBNP/CKMB mass and NTproBNP/EF ratios can distinguish TTC from STEMI at an early stadium. The most accurate marker is the NTproBNP/TnI ratio.

The oldest patient with takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is a rare condition that affects mainly aging women. According to a retrospective review, patients with TTC accounted for approximately 2% of all the patients with suspected acute coronary syndrome (ACS). A few reports indicated that the average age of TTC patients was 68 years, although children or young adults may also be affected. In US and Europe, a number of contemporary TTC studies report that 90% of patients with TTC are women aged 65–70 years. Meta analysis showed that the age ranged from 10 to 89 years. [1] There was also one case study of a 90-year-old patient with TTC ― the oldest patient known so far. In that case, the patient died during the course of treatment from severe multi-organ failure. [2] In the present case report, we present a 98-years old woman with TTC admitted to our clinic. A 98-years old patient was admitted to our clinic because of significant chest pain and general weakness accompanied by hypotension that required catecholamine administration with ST-segment elevation in the anterolateral leads in ECG. The patient suffered from hypertension and third stage of chronic kidney disease. Urgent cardiac catheterization and ventriculography confirmed the absence of any critical coronary disease, but also the presence of a typical apical ballooning and midventricular hypokinesis. Troponin I (TnI) at admission was 5.555 ng/mL and creatine kinase soenzyme MB (CK-MB) mass was 14.5 ng/mL. Inflammatory parameters were not elevated, whereas N-terminal pro brain natriuretic peptide (NT-proBNP) concentration was markedly elevated, at 18,623 pg/mL. NT-proBNP/TnI ratio was 3352.48 on the first day and even higher after 24 h, at 7113.36. This markers profile is characteristic of TTC. There is a relatively small increase in creatine kinase and troponin concentrations in relation to the extent of wall motion abnormalities. BNP is always elevated in patients with TTC and is higher than in patients with ST-segment elevation myocardial infarction. Some researchers suggest that TTC can be distinguished from ACS on the basis of the characteristic profile of cardiac markers consisting of a sudden increase in the concentration of NT-proBNP in the first few days when there is only a small increase in markers of myocardial necrosis (the ratio of NT-pro BNP/troponin). [3]

Influence of echocardiographic and radiographic characteristics on atrial sensing amplitude in patients with Linox Smart S DX defibrillation leads.

BACKGROUND Single-lead for implantable cardioverter-defibrillator (ICD) with floating atrial sensing dipole is a new diagnostic tool with the potential advantage in terms of arrhythmia discrimination. We sought to determine whether right heart size and dipole position influence atrial sensing. METHODS Atrial sensing (AS) amplitude was measured during implantation (PP, periprocedural), predischarge (IHFU, in-hospital follow-up) and 3-6 months after the procedure (AFU, ambulatory follow-up). Results were related to atrial dipole position in the right atrium (RA) on the basis of chest X-ray examination as well as right heart dimensions at echocardiography. RESULTS Twenty-four patients were included into final analysis. In 14 (58.3%) patients, sensing dipole was located in regions 1 and 2 of the RA. AS amplitude was greater in regions 1 and 2 when com¬pared to other locations (3.15 vs. 1.2 mV, p = 0.045, 7.53 vs. 3.8 mV, p < 0.001 and 5.63 vs. 2.44 mV, p = 0.017 for PP measurements, IHFU and AFU, respectively). There was a significant negative correlation between AS-PP and short RA dimension (RADs) (r = -0.56, p = 0.02), AS-IHFU and RA area (RAA) (r = -0.45, p < 0.05), AS-AFU and long RA dimension (RADl) (r = -0.46; p = 0.02), AS-AFU and RADs (r = -0,48, p = 0.02), and AS-AFU and RAA (and r = -0.52, p < 0.01). There was no relationship between AS and other right heart dimensions. CONCLUSIONS Larger RA size and low sensing dipole location were associated with lower AS amplitude in single-lead dual chamber ICD.

Toll-like receptor expression and apoptosis morphological patterns in female rat hearts with takotsubo syndrome induced by isoprenaline

Aims: Toll‐like receptors (TLR) and apoptosis were indicated as important factors in heart failure. Our aim was to characterize the morphological pattern of apoptosis, TLR2, TLR4, and TLR6 expression in female rat hearts in the model of takotsubo syndrome (TTS). Main methods: 60 Sprague‐Dawley female rats were treated with a single dose of 150 mg/kg b.wt. of isoprenaline (ISO) or 0.9% NaCl (controls). Hearts were collected 24, 48, 72 h and 7 days post‐ISO injection. 32/60 hearts were used in immunohistopathological studies and 28/60 in real time. Key findings: Apoptosis was observed 24 h post‐ISO in cardiomyocytes, 24, 48, 72 h and 7 days post‐ISO in infiltrating inflammatory cells, 7 days post‐ISO in endothelial cells of vessels. Diffuse TLR4CD68 (CD68, a macrophage marker) and TLR6CD68 positive cells and TLR2, TLR4, TLR6 mononuclear cells were observed in both acute and recovery phase of TTS. In the foci located in the neighborhood of damaged (necrotic/apoptotic) cardiomyocytes in TTS, high (strong) protein expression of TLR2 (TLR2high) was observed: 24, 48, 72 h post‐ISO; TLR4high – 48 and 72 h post‐ISO; TLR6high – 48 h post‐ISO. Whereas in cardiomyocytes of remote myocardium: TLR2high – 72 h post‐ISO; TLR4high – 24 and 72 h post‐ISO; TLR6high – 24 h post‐ISO. TLR2 mRNA was down‐regulated 48 and 72 h post‐ISO whereas TLR4 up‐regulated 7 days post‐ISO. Significance: The expression pattern of apoptosis and TLR differs in the course of TTS in comparison with the control rats. We hypothesize that innate immunity and apoptosis may play a crucial role in TTS pathophysiology.

Reverse Takotsubo syndrome in a patient with diagnosed multiple sclerosis

Takotsubo cardiomyopathy is a temporary systolic dysfunction of the myocardium, unrelated to flow alterations in coronary arteries. However, clinical presentation and the results of laboratory tests as well as electrocardiogram (ECG) may suggest acute coronary syndrome. It typically affects women over 50 years old and is usually associated with a sudden, severe emotional situation. We present a case of a 43-year-old woman who was admitted to the Department with suspicion of ST segment elevation myocardial infarction. She presented chest pain and retrosternal discomfort lasting 5 h before admission, dyspnoea, numbness of the left arm, nausea, and headache. Moreover, six years ago the patient was diagnosed with multiple sclerosis (MS). On admission, during the physical examination, tachycardia of 105 bpm was noted as well as ptosis of the upper left eyelid. In ECG an elevation of ST segment in V1–V3 leads and ST segment depression in II, III, aVF, V4, and V5 leads were reported (Fig. 1). The patient was immediately transported from the Emergency Room to the Coronary Care Unit. No significant changes in coronary arteries were found in coronary angiography (Fig. 2), but a dyskinesia of posterior basal and anterior basal segments of the left ventricle was discovered in the ventricle angiography (Fig. 3). The laboratory tests showed elevated levels of troponin I (2.44 ng/mL) and creatinine kinase-MB mass (9.3 ng/mL). In the echocardiography akinesia of basal segments and hypokinesia of middle segments of all the left ventricular walls was reported, with a moderate tricuspid regurgitation. Computed tomography of the head ruled out intracranial bleeding. Fresh relapse of MS was also ruled out based on neurological examination. In anamnesis the patient associated the outburst of pain with severe stress (suspicion that her daughter has MS). The patient was diagnosed with reverse Takotsubo syndrome (TTS). In follow-up echocardiography, performed in the eighth day of hospitalisation, systolic function of all the segments of the left ventricle has returned. Also, normalisation of ST segment was observed in ECG. In major clinical registries up to 40% of cases of TTS were described as “atypical”, of which around 2/3 were, similarly to the presented, reverse TTS [Kurowski V et al. Chest, 2007; 132: 809–816]. In comparison with other types of TTS, patients diagnosed with the reverse type are younger. However, no differences in clinical data, angiographic or laboratory findings, or prognosis were found among patients with typical and atypical TTS. Also, some cases of atypical TTS associated with severe neurological disorders were described in the literature, including one case of MS relapse. The presented case indicates the need for a more diverse look at TTS, which can also present itself in an atypical form. It is also important to remember that it can be induced by acute neurological disorders, even though it was not the case in this situation. Figure 1. Electrocardiogram performed in admission

Chemotherapy-Induced Takotsubo Syndrome

Cardiovascular complications are a significant problem in systemically treated cancer patients. One such complication is Takotsubo cardiomyopathy, also known as Takotsubo syndrome. It is most frequently defined as a sudden and transient left or right ventricular systolic dysfunction; mimicking acute coronary syndrome, but without the associated changes in coronary arteries. Takotsubo syndrome is a relatively little known complication that appears in the course of oncological treatment, and its incidence has not yet been established. In this study, we reviewed Medline database according to case reports concerning takotsubo syndrome appearing after systemic treatment in oncological patients. We took into consideration all types of anticancer drugs. We reviewed the changes reported in the electrocardiography, echocardiography, and coronary angiography, and also the level of troponin, a marker of acute coronary syndrome elevation. In view of the increasing frequency of cardiac complications reported in patients receiving systemic oncological treatment, Takotsubo syndrome appears to be underdiagnosed. However, the syndrome may be linked to potentially fatal complications such as cardiogenic shock or cardiac arrest. Therefore, it seems essential to carry out appropriate diagnostic procedures for every patient experiencing clinical side effects of onco-pharmacotherapy. In patients with chest pain and dyspnea during or after treatment, Takotsubo syndrome should be considered, particularly that the syndrome requires a different therapy approach than that used in a coronary syndrome. Diagnostic procedures should include echocardiogram and the assessment of myocardial necrosis markers and natriuretic peptides.

Usefulness of CorMatrix-based tricuspid valve repair in the treatment of infective endocarditis

A 34-year-old man addicted to heroin and mephedrone was transported to the cardiac surgery unit from the Isolation Hospital due to infective endocarditis (IE) of the tricuspid valve (TV) with severe regurgitation. Blood cultures indicated an increase in Staphylococcus aureus MSSA — a targeted antibiotic treatment with cloxacillin 6 × 2 g IV was added. The echocardiography revealed a large vegetation on the anterior leaflet of the TV, 31 × 20 mm in size, right atrium enlargement, and severe TV regurgitation (Fig. 1). Until recently, the only treatment options for IE causing significant damage to the TV were replacement of the valve with a biological or mechanical implant or advanced valvuloplasty. These methods, however, carry a risk of reinfection, dysfunction of the artificial prosthesis, as well as the potential complications inherent to aggressive treatment with vitamin K antagonists (VKA). Employing a CorMatrix patch may present an alternative method for treating IE. CorMatrix is an extracted extracellular matrix to which growth factors, matricellular proteins, glycosaminoglycans, and adhesion factors were applied. After implantation into human tissue, CorMatrix functions as a scaffold onto which the body’s own cells migrate, depending on the location of the implant. The material also promotes the migration of leukocytes — a crucial property when treating IE because it prevents further reinfection. Before opening the patient’s chest, the surgeon crafts a tubular CorMatrix patch, using the dimensions of the TV established during the pre-surgery cardiac echo as a template (the tricuspid annular diameter and the distance from the annulus to the papillary muscles in diastole). After sternotomy and removing the native TV, the surgeon implants the newly crafted valve to the native annulus and the papillary muscles. A CorMatrix-reconstructed TV (15 × 7 cm patch) was implanted. The intraoperative transoesophageal echocardiogram indicated the proper functioning of the CorMatrix prosthesis with only an insignificant regurgitation (Fig. 2). The patient was discharged from the intensive care unit two days after the surgery. During the following days, a gradual normalisation of biochemical parameters was observed. In good overall condition, the patient was transferred to the Isolation Hospital to continue intravenous antibiotic treatment. Six months after the surgery, a follow-up cardiac echo showed no tricuspid regurgitation and no reinfection. Until now, IE of the TV carried a high risk of reinfection. Additionally, there are no valves dedicated specifically to the tricuspid configuration available. The long-term outcomes of the implantation of a CorMatrix valve shed a new light on the treatment of IE of the TV. An additional advantage of the method is that it does not require any anticoagulant treatment with all abbreviation should be spelled out VKA, which often has a great impact on the quality of life of young patients.

Unusual Mass in the Left Ventricle

All authors have nothing to declare. H erein we present unique imaging of cardiac involvement in cysticercosis. A 39-year-old man was hospitalized at the Department of Cardiology with suspected cardiac tumor. Electrocardiogram was normal. On echocardiography we confirmed the presence of an abnormal mass in the left ventricle (LV; Figure). It was hyperechogenic and approximately 10×15 mm in size. Additionally, we noticed many hyperechogenic masses in the liver (Figure D). Computed tomography demonstrated multiple small, calcified cysts in the liver. After consultation at the Department of Infectious Diseases, cysticercosis was diagnosed. The diagnosis was established based on typical predisposing factor (eating under-cooked pork meat), the presence of multiple small, calcified cysts in the liver, as well as specific antibodies in serum. On consultation with the cardiac surgeon, conservative treatment was recommended. The patient has been followed for 16 years. At the time of writing he felt good and had no cardiac symptoms. On steady-state free procession magnetic resonance imaging (MRI), we noted a hypointense, well-circumscribed ovoid mass fixed to the endocardial surface of the anterior apical segment. On T1-weighted and T1-weighted fat-saturated MRI the mass was hyperintense, with small hypointense parts. On T2-weighted MRI, the mass was hyperintense. After gadolinium, late enhancement was present at the