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Broken Heart Syndrome: A Risk of Teenage Rhinoplasty

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Abstract

“Broken heart” syndrome is a rare phenomenon characterized by transient ballooning of the left ventricle and chronic heart failure, usually presenting in postmenopausal women. It is formally known as acute stress-induced cardiomyopathy and, although described in the cardiology literature, it has not been previously described in plastic surgery patients. It is thought to occur secondary to increased catecholamine levels. This case report outlines two instances of the syndrome occurring in teenage girls undergoing cosmetic rhinoplasty. Level of Evidence: 5

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... [4][5][6] Pathophysiology Although many theories have been proposed, the precise pathophysiology of the disease remains largely unclear. [4][5][6][7][8] The key event seems to be a supraphysiologic increase of catecholamines. The high concentration triggers a negative feedback response that induces a switch from myocytestimulating to myocyte-inhibiting adrenoreceptors on the surface of the myocytes. ...
... These can be followed by heart failure and subsequent decreased blood oxygenation, hypotension, shock, and death. 4,5,7,10 This overlap in symptoms makes ACS the leading differential diagnosis. The clinical image and EKG will resemble an acute ST-elevated myocardial infarction of the anterior wall seen with occlusion of the proximal left anterior descending artery. ...
... In many reported cases of TCM, endogenous or exogenous catecholamines or both are the triggering factor. 4,5,7 Psychological triggering factors such as anxiety or an intense positive emotion are more common in women, whereas somatic triggering factors such as the physical stress from an underlying disease are more frequent in men. 5,6 It is increasingly recognized that TCM can also occur with exogenous catecholamines as a trigger, for example in systemic administration of epinephrine. ...
Article
Broken heart syndrome, more commonly known as Takotsubo cardiomyopathy (TCM), is an acute cardiac condition. It is characterized by regional cardiac wall motion abnormalities triggered by physical or emotional stress or administration of catecholamines such as epinephrine. The initial clinical presentation is similar to an acute coronary syndrome and must be ruled out. Visualization of the characteristic wall motion will trigger the diagnosis of TCM. In this case report, we present a 50-year-old woman with additional liposuction and fat grafting after autologous breast reconstruction. Shortly after infiltration with a solution containing epinephrine to achieve vasoconstriction, hypotension and bradycardia was noticed. This escalated into full asystole for which cardiac resuscitation was required. ST-elevations and a decrease in systolic function were clear indicators for urgent coronarography and ventriculography. These confirmed the diagnosis of TCM. Infiltration with epinephrine-containing products to achieve local vasoconstriction is used routinely. Medical professionals should be aware that this can trigger a TCM with an estimated mortality rate of 5%. No evidence of a specific preventive measure currently exists. We know that women with a neurologic or psychiatric comorbidity and high levels of stress are more at risk. Reducing stress and anxiolytic medication prior to surgery could be useful. We also know that the cardiac wall motion abnormality is mainly related to β-adrenoreceptors. The use of a selective α-adrenoreceptor agonist could be considered. Further research in the pathophysiology and incidence of TCM could improve identification of patients at risk and lead to more effective prevention and treatment. Level of Evidence: 5
... There are not many reports in the medical literature on takotsubo syndrome associated with aesthetic procedures. The plastic surgeon should be aware of its clinical characteristics and how to establish a timely diagnosis and effective treatment [7]. ...
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Takotsubo cardiopathy is a specific type of heart attack commonly linked with sudden emotional stress and usually presenting in postmenopausal women. It is thought to occur through direct catecholamine-associated myocardial toxicity. The case report described herein outlines an instance of the syndrome arising during a liposuction on a 24-year-old female patient with a history of family stress. Present their clinical, laboratory, transthoracic echocardiogram, and electrocardiographic. During the procedure, epinephrine at a dilution of 1:1,000,000 was used and 3 h after the beginning of the surgery, she developed a cardiorespiratory arrest, requiring ICU care. A transthoracic echocardiogram revealed normal right ventricle systolic function with hypokinesis of the middle and apical segments in the left ventricle and hypercontractility of the basal segments, with an ejection fraction of 30%, and presenting a total recovery on postoperative day 37. Our report documents the first case occurring in a young patient undergoing liposuction.
... First, stress cardiomyopathy may be the major cause, based on patients' echocardiographic data. Stress cardiomyopathy has been reported after non-cardiac surgery (including cosmetic surgery) [18] and may be the cause or result of OHCA [19,20]. Most of our patients exhibited moderate-to-severe left ventricular systolic dysfunction (mean left ventricular ejection fraction, 34%±15.53%). ...
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Background: Cardiac arrest during or after office-based cosmetic surgery is rare, and little is known about its prognosis. We assessed the clinical outcomes of patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics. Methods: Between May 2009 and May 2016, 32 patients who developed cardiac arrest during or after treatment at cosmetic surgery clinics were consecutively enrolled. We compared clinical outcomes, including complications, between survivors (n=19) and non-survivors (n=13) and attempted to determine the prognostic factors of mortality. Results: All 32 of the patients were female, with a mean age of 30.40±11.87 years. Of the 32 patients, 13 (41%) died. Extracorporeal life support (ECLS) was applied in a greater percentage of non-survivors than survivors (92.3% vs. 47.4%, respectively; p=0.009). The mean duration of in-hospital cardiopulmonary resuscitation (CPR) was longer for the non-survivors than the survivors (31.55±33 minutes vs. 7.59±9.07 minutes, respectively; p=0.01). The mean Acute Physiology and Chronic Health Evaluation score was also higher among non-survivors than survivors (23.85±6.68 vs. 16.79±7.44, respectively; p=0.01). No predictor of death was identified in the patients for whom ECLS was applied. Of the 19 survivors, 10 (52.6%) had hypoxic brain damage, and 1 (5.3%) had permanent lower leg ischemia. Logistic regression analyses revealed that the estimated glomerular filtration rate was a predictor of mortality. Conclusion: Patients who developed cardiac arrest during or after cosmetic surgery at office-based clinics experienced poor prognoses, even though ECLS was applied in most cases. The survivors suffered serious complications. Careful monitoring of subjects and active CPR (when necessary) in cosmetic surgery clinics may be essential.
... Although endogenous epinephrine discharge has been widely implicated in the onset of TS, paradoxically, only isolated cases have occurred after exogenous epinephrine for medical and dental care. 62 Our comprehensive literature search identified 12 case reports of TS arising perioperatively with procedures in the oral and maxillofacial region in association with local or topical sympathomimetics (epinephrine, felypressin), including 6 without specification of dose, 8,9,13,14,18,22 4 designated with therapeutic doses of epinephrine ranging from 0.018 to 0.04 mg, 14,17,25,27 and 2 cases attributed to iatrogenic dosing. 11,26 Abraham et al 12 reported a series of 9 patients who developed TS after intravenous catecholamine infusions for a variety of events, 1 of whom was given ''1 mg'' of epinephrine while undergoing a facelift BROOKS, WARBURTON, AND CLARK and the entry for hemodynamic support was listed as ''none.'' ...
Article
Purpose: Takotsubo syndrome (TS) is an acute and potentially serious cardiac disorder that is often attributed to an exuberant catecholaminergic response to a severely physical or emotional event. As there is a paucity of information in the dental literature on TS, this article will provide an overview of this uncommon syndrome, including clinical presentation, demographic characteristics, etiopathogenesis, diagnosis, management, and recovery, particularly emphasizing its occurrence with oral and maxillofacial procedures. Patients and methods: A PubMed search with the keyword "takotsubo" for publications from 1991 through May 2018 yielded 3,778 articles. Case reports and case series of TS associated with surgical and nonsurgical procedures in the oral and maxillofacial region were reviewed. Other cases were identified using a defined search strategy. Results: The literature search identified 28 documented episodes of TS that occurred with head and neck surgical procedures, mostly sinus, carotid, nasal, and cancer reconstruction surgical procedures, and notably, 3 cases occurred concurrently with dental extractions. In all of the featured patients, some degree of cardiovascular impairment developed and phenotypic overlap with acute occlusive coronary disease was shown. Most patients recovered within 2 weeks, and recovery in the remainder extended up to 3 months. Conclusions: On rare occasions, TS has been reported in association with oral and maxillofacial procedures. As stress appears to be a precipitating factor in the development of TS, perioperative efforts should be instituted to reduce an adrenergic cascade.
... In clinical practice, TC may develop during surgical or invasive procedures, following treatment of allergic conditions, bee, hymenoptera or wasp sting, in association with hypotension (e.g. during general anesthesia) or vasovagal reaction [26,30]. TC was described after ophthalmologic [2], oto-rhino-laryngologic [15] and orthopedic procedures [14]. Rarely, transient LV dysfunction was also reported after epinephrine administration in patients with cardiac arrest [5,42]. ...
Article
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A case report: The authors describe a case of a 58-year-old, otherwise healthy female, with TC which occurred after intravenous injection of 1 mg of epinephrine against cardiac arrest provoked by pneumoperitoneum performed before planned laparoscopic cholecystectomy. She was admitted 3 days earlier due to biliary colic following a dietary mistake. Bradycardia followed by asystole took place immediately after carbon dioxide insufflation into the peritoneal cavity. Normal heart rhythm, with transient tachycardia, recurred after a short cardiac massage, intravenous atropine and epinephrine administration as well as pneumoperitoneum decompression. ECG after the episode showed nonspecific ST segment changes. Left ventricular dysfunction assessed in echocardiography as contractile abnormalities and decreased global longitudinal strain (GLS) represented an unusual type of TC - intermediate between mid-basal and focal one. These abnormalities, involving mainly the posterior wall, resolved rapidly within 24 hours without any specific treatment. The absence of coronary artery disease was confirmed by 128-row multidetector computed tomography. TC should be considered as a potential complication of epinephrine action; however, different factors related to laparoscopic procedure including general anesthesia, intubation, underlying disease and mental stress might have been also involved in TC triggering in the case presented.
... In a study, nine cases of stress cardiomyopathy occurred immediately after intravenous administration of epinephrine (six cases) or dobutamine (three cases) [11]. As in our case, a study report two cases of TTC occurring in teenage girls undergoing cosmetic rhinoplasty [12]. In these cases, injection of xylocaine with epinephrine was realized into subcutaneous planes. ...
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Introduction: Takotsubo cardiomyopathy (TTC) is an entity firstly described in 1991, characterized by acute but reversible left ventricular systolic dysfunction in the absence of atherosclerotic coronary artery disease. Acute physical or psychological stresses seem to be the most common causes of takotsubo. We reported a case of atypical TTC, during a dental procedure, including 2% xylocaine injection into gum. Case Report: A 51-year-old Caucasian female with a past medical history of depression underwent dental procedure. The dentist injected a solution of 2% xylocaine into the gum and three minutes following the procedure, the patient complained for chest pain, during one hour. Electrocardiogram revealed T waves inversions into inferolateral leads. Troponin level performed at admission was 23 ng/mL (N ≤ 0,05). Clinical examination, echocardiography and coronary angiography were normal. Cardiac magnetic resonance imaging (MRI) found a global left ventricular hypokinesis, with ejection fraction of 40%, without late Gadolinium enhancement. Conclusion: This case reports an atypical presentation of TTC, induced by xylocaine injection, during the dental procedure. This is an unexpected cardiac side effect of the xylocaine drug mechanism. This case has an interest for the specialties of emergency medicine, cardiology and for dentists usual practice.
... Stresi azaltmak için ortamın sessiz olması, adrenerjik stimulan ve antikolinerjik ilaçların dikkatli kullanılması gerektiği bildirilmiştir (18). Genel anestezi altında rinoplasti (19) ve nazal fraktür ameliyatları sonrasında (20), Sheehan sendromu (21), spontan vaginal doğum (22), kronik anksiyete (23), myastenia gravis (24), akut pankreatit (25), addison (26) sonrasında TK görülmüştür. Genel anestezi, ameliyat, doğum, kronik hastalıklar, endokrin sistem hastalıklarında oluşan stres TK'yı tetiklemektedir. ...
Article
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Takotsubo cardiomyopathy (TC) is acute and temporal dysfunction of the left ventricle, and characterized by ballooning usually involving the apical region of the left ventricle without significant stenosis in coronary arteries. It is generally encountered after emotional or physical stress in women in the post-menopausal period. This left ventricular dysfunction recovers within days or weeks. Rarely, cardiogenic shock develops due to severe ventricular dysfunction, which may result in death. Although its pathophysiology is not fully understood, increased cathecolamines are considered to play an important role. Stunned myocardium, hypertension, chronic obstructive lung disease, decreased estrogen level, small vessel disease, myocarditis, insufficient metabolism of fatty acids of myocardium was also suggested. Sudden onset chest pain mimicking Acute coronary syndrome, dyspnea, syncope, ECG alterations, slight increase in myocardial enzymes may be detected. Frequently, such patients in coronary intensive care unit are transferred to general intensive care unit for respiratory support. To the best of our knowledge, there has been no TC syndrome in the literature, which develops in a patient under intensive stress due to an extraordinary long term hospitalization.
Article
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Takotsubo cardiomyopathy (TTS) has become a recognised clinical entity since the Japanese scientist Sato first described it in 1990. Despite an increasing number of confirmed cases, especially during the COVID-19 pandemic, its pathophysiology remains incompletely understood, and decision-making differs in the diagnosis and treatment. In addition, it is not evident whether a significant increase in TTS is due to better understanding among practitioners and widespread access to coronary angiography, or if it is a reflection of an actual increase in incidence. We analysed a series of international research studies from 1990 to 2021. Beyond epidemiology and clinical presentation, we evaluated and summarised fundamental knowledge about various predisposing factors, with particular attention to the iatrogenic impact of certain drugs, namely antidepressants, chemotherapy, and antiarrhythmics. Furthermore, we highlighted the main pathophysiological theories to date. In addition, based on published studies and clinical cases, we investigated the role of numerous diagnostic approaches in the differential diagnosis of TTS and identified predictors of TTS complications, such as cardiogenic shock, ventricular fibrillation, and left ventricular thrombi. Accordingly, we sought to propose a diagnostic algorithm and further treatment management of TTS under the presence of possible complications to help practitioners make more informed decisions, as the initial presentation continues to pose a challenge due to its close similarity to acute coronary syndrome with ST-elevation. In conclusion, this article examines Takotsubo cardiomyopathy from different perspectives and, along with future systematic reviews and meta-analyses, can be of particular interest to practising cardiologists and researchers in developing clinical guidelines.
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Background Because many cosmetic surgery clinics are not adequately equipped to handle emergent conditions, patients often come to a university hospital when problems occur during or after cosmetic surgery. However, few in-depth studies have been conducted of this issue. Therefore, we investigated emergency department visits due to complications associated with cosmetic surgery. Methods A retrospective chart review was conducted of 38 patients who visited the emergency department of the authors’ institution due to complications associated with cosmetic surgery from July 2014 to June 2017. Results There were more women than men (30 women vs. 8 men). Their mean age was 32.4 years (range, 19–57 years). Upon presentation to the emergency department, patients’ vital signs and mental status were usually normal (27 normal vs. 11 abnormal). The types of surgery included blepharoplasty, rhinoplasty, malar/orthognathic surgery, mammaplasty, liposuction, fat grafting, and filler and botulinum toxin injections. Most patients required hospitalization (26 admitted vs. 12 discharged). Eight of the hospitalized patients required intensive care unit care, of whom two died and three experienced brain death or had permanent neurologic sequelae. Conclusions The complications were usually minor problems, despite the need for hospitalization, but some complications were life-threatening. We recommend close monitoring and maintaining an adequate injection capacity for intravenous sedative anesthesia. When any symptom or sign of a complication occurs, it is best to transfer the patient to a university hospital as soon as possible. Taking a careful medical history is always needed, even for minor procedures.
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Flexible bronchoscopy is a safe medical procedure, but the incidence rate of major complications is 0.08-0.3%. Here, we report 2 cases of stress induced cardiomyopathy, which developed immediately after flexible bronchoscopy. Stress related cardiomyopathy was confirmed by EKG, echocardiography, and coronary angiogram. The cardiac functions of these patients were fully recovered with conservative treatment. Although, the pathogenesis of stress related cardiomyopathy is not well understood, post-bronchoscopy tachycardia or arrhythmia is thought to be associated with hypoxemia or catecholamine excess. Because the clinical presentation is quite similar to acute myocardial infarction, discrete evaluations are required for appropriate treatment.
Article
Takotsubo cardiomyopathy (TTC) is an increasingly recognized, reversible cardiomyopathy with a clinical presentation that mimics an acute coronary syndrome but without evidence of obstructive coronary lesions. Typical presentation involves chest pain and/or dyspnea, transient ST-segment elevation on the electrocardiogram, and a modest increase in cardiac troponin. Cardiac imaging demonstrates wall-motion abnormalities that extend beyond the territory of a single epicardial coronary artery, and the absence of obstructive coronary lesions. Supportive treatment leads to spontaneous, rapid recovery of ventricular function, but about 10% of patients have recurrent events. This article reviews the defining features and clinical profile of TTC.
Article
Takotsubo cardiomyopathy (TTC) is a recently recognized clinical syndrome characterized by transient ventricular dysfunction in the absence of obstructive coronary artery disease. TTC primarily affects postmenopausal women; TTC in children and adolescents is only rarely reported. Furthermore, simultaneous occurrence of Takotsubo cardiomyopathy and primary electrical diseases has been previously reported in only four recent cases of female patients with congenital long QT syndrome. Here, we report the novel association of catecholaminergic polymorphic ventricular tachycardias and a midventricular type of TTC observed in a young female patient.
Article
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Reversible left ventricular dysfunction precipitated by emotional stress has been reported, but the mechanism remains unknown. We evaluated 19 patients who presented with left ventricular dysfunction after sudden emotional stress. All patients underwent coronary angiography and serial echocardiography; five underwent endomyocardial biopsy. Plasma catecholamine levels in 13 patients with stress-related myocardial dysfunction were compared with those in 7 patients with Killip class III myocardial infarction. The median age of patients with stress-induced cardiomyopathy was 63 years, and 95 percent were women. Clinical presentations included chest pain, pulmonary edema, and cardiogenic shock. Diffuse T-wave inversion and a prolonged QT interval occurred in most patients. Seventeen patients had mildly elevated serum troponin I levels, but only 1 of 19 had angiographic evidence of clinically significant coronary disease. Severe left ventricular dysfunction was present on admission (median ejection fraction, 0.20; interquartile range, 0.15 to 0.30) and rapidly resolved in all patients (ejection fraction at two to four weeks, 0.60; interquartile range, 0.55 to 0.65; P<0.001). Endomyocardial biopsy showed mononuclear infiltrates and contraction-band necrosis. Plasma catecholamine levels at presentation were markedly higher among patients with stress-induced cardiomyopathy than among those with Killip class III myocardial infarction (median epinephrine level, 1264 pg per milliliter [interquartile range, 916 to 1374] vs. 376 pg per milliliter [interquartile range, 275 to 476]; norepinephrine level, 2284 pg per milliliter [interquartile range, 1709 to 2910] vs. 1100 pg per milliliter [interquartile range, 914 to 1320]; and dopamine level, 111 pg per milliliter [interquartile range, 106 to 146] vs. 61 pg per milliliter [interquartile range, 46 to 77]; P<0.005 for all comparisons). Emotional stress can precipitate severe, reversible left ventricular dysfunction in patients without coronary disease. Exaggerated sympathetic stimulation is probably central to the cause of this syndrome.
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Stress cardiomyopathy, also referred to as Takotsubo cardiomyopathy, is an increasingly recognized clinical syndrome characterized by acute reversible apical ventricular dysfunction. We hypothesize that stress cardiomyopathy is a form of myocardial stunning, but with different cellular mechanisms to those seen during transient episodes of ischemia secondary to coronary stenoses. In this syndrome, we believe that high levels of circulating epinephrine trigger a switch in intracellular signal trafficking in ventricular cardiomyocytes, from G(s) protein to G(i) protein signaling via the beta(2)-adrenoceptor. Although this switch to beta(2)-adrenoceptor-G(i) protein signaling protects against the proapoptotic effects of intense activation of beta(1)-adrenoceptors, it is also negatively inotropic. This effect is greatest at the apical myocardium, in which the beta-adrenoceptor density is greatest. Our hypothesis has implications for the use of drugs or devices in the treatment of patients with stress cardiomyopathy.
Article
Broken heart syndrome/ tako-tsubo cardiomyopathy is a recently described stress- induced cardiomyopathy that is often associated with symptoms suggestive of acute coronary ischemia including chest pain, ST changes and elevated cardiac enzymes. In most cases the syndrome is triggered by profound physical or psychological stress and has an increased incidence in post menopausal women.Here we describe a patient who was admitted with nonspecific abdominal pain and symptoms of ileus that went onto develop Tako-tsubo cardiomyopathy as confirmed by left ventriculography. Unlike previously reported cases, our patient appeared to develop the syndrome as a result of chronic rather than acute stress.
Article
The aim of this study was to report a series of patients with stress cardiomyopathy precipitated by the intravenous administration of catecholamines and beta-receptor agonists. Stress cardiomyopathy is a syndrome of transient cardiac dysfunction precipitated by intense emotional or physical stress. Excessive sympathetic stimulation is believed to be central to the pathogenesis of this disorder, but a causal link has not been convincingly demonstrated. We observed 9 cases of stress cardiomyopathy precipitated immediately by the intravenous administration of epinephrine (n = 6) or dobutamine (n = 3). Patients were evaluated with coronary angiography and with serial echocardiography, electrocardiography, and cardiac enzymes. The median age was 44 years (interquartile range [IQR]: 30 to 48 years), and 7 (78%) were woman. Troponin-I was mildly elevated (median 4.07 ng/ml, IQR: 0.47 to 5.63 ng/ml), but none of the patients undergoing angiography had obstructive coronary disease. All patients developed corrected QT interval (QTc interval) prolongation (median QTc interval 504 ms, IQR: 477 to 568 ms) within 24 h of receiving drug. All 3 previously described variants of left ventricular "ballooning" (apical, midventricular, and basal) were observed. The median ejection fraction on admission was 35% (IQR: 35% to 40%). During follow-up (median 7 days, IQR: 4 to 13 days) there was recovery of left ventricular systolic function in all patients (median ejection fraction 55%, IQR: 40% to 60%, p < 0.001 vs. admission). Exposure to catecholamines and beta-receptor agonists used routinely during procedures and diagnostic tests can precipitate all the features of stress cardiomyopathy, including cardiac isoenzyme elevation, QTc interval prolongation, and rapidly reversible cardiac dysfunction. These observations strongly implicate excessive sympathetic stimulation as central to the pathogenesis of this unique syndrome.
Article
Five patients with typical myocardial stunning were presented. They had chest pain and had electrocardiographic abnormalities matching the symptoms of acute myocardial infarction (AMI) but had no coronary artery stenoses on angiogram (CAG). The prevalence of cases with these clinical manifestations was 1.2% among 415 consecutive AMI patients who were examined invasively. The electrocardiographic abnormalities varied; ST elevations were observed in 4 patients, R waves decreased transiently in one, and Q waves developed in one patient. Typical left ventriculogram (LVG) was akinesis in the apical, diaphragmatic and/or anterolateral segments, but hyperkinesis in the basal segments. This akinesis was transient and resolved in 7 days. CAG revealed diffuse multi-vessel spasms in 2 patients, which were also observed in additional 2 patients after ergonovine administration. The intracoronary administration of nitroglycerin disclosed no coronary artery stenoses in any of the patients.
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The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy, is characterized by transient wall-motion abnormalities involving the left ventricular apex and mid-ventricle in the absence of obstructive epicardial coronary disease. In this paper, we review case series that report on patients with the transient left ventricular apical ballooning syndrome to better characterize patients presenting with the syndrome. We identified 7 case series that reported on at least 5 consecutive patients with the transient left ventricular apical ballooning syndrome. The syndrome more often affects postmenopausal women (82% to 100%) (mean age, 62 to 75 years). Patients commonly present with ST-segment elevation in the precordial leads, chest pain, relatively minor elevation of cardiac enzyme and biomarker levels, and transient apical systolic left ventricular dysfunction despite the absence of obstructive epicardial coronary disease. An episode of emotional or physiologic stress frequently precedes presentation with the syndrome. The in-hospital mortality rate seems to be low, as does the risk for recurrence.
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Takotsubo cardiomyopathy (TCM) is a relatively new concept in cardiovascular disease. The clinical symptoms of TCM are similar to those of a myocardial infarction, but both the mechanism and the management of TCM are different from those of myocardial infarction. The cause of TCM is unclear, but it is suggested to occur in conjunction with excessive circulating catecholamines due to stress. Thus, control of the stress reaction and restriction of catecholamine levels are considered important for prevent of TCM onset. We report the dental management of a patient with intellectual disability who had anamnesis of TCM and cardiopulmonary arrest under restraint during a previous dental appointment in another dental clinic. We used intravenous sedation with both midazolam and propofol, by which the excessive hormonal reaction that caused TCM onset and cardiopulmonary arrest was controlled, for dental treatment in our facility. All planned dental treatment was then performed without any problems.
Article
Transient left ventricular apical ballooning syndrome (TLVABS) is an acute cardiac syndrome mimicking ST-segment elevation myocardial infarction characterized by transient wall-motion abnormalities involving apical and mid-portions of the left ventricle in the absence of significant obstructive coronary disease. Searching the MEDLINE database 28 case series met the eligibility criteria and were summarized in a narrative synthesis of the demographic characteristics, clinical features and pathophysiological mechanisms. TLVABS is observed in 0.7-2.5% of patients with suspected ACS, affects women in 90.7% (95% CI: 88.2-93.2%) with a mean age ranging from 62 to 76 years and most commonly presents with chest pain (83.4%, 95% CI: 80.0-86.7%) and dyspnea (20.4%, 95% CI: 16.3-24.5%) following an emotionally or physically stressful event. ECG on admission shows ST-segment elevations in 71.1% (95% CI: 67.2-75.1%) and is accompanied by usually mild elevations of Troponins in 85.0% (95% CI: 80.8-89.1%). Despite dramatic clinical presentation and substantial risk of heart failure, cardiogenic shock and arrhythmias, LVEF improved from 20-49.9% to 59-76% within a mean time of 7-37 days with an in-hospital mortality rate of 1.7% (95% CI: 0.5-2.8%), complete recovery in 95.9% (95% CI: 93.8-98.1%) and rare recurrence. The underlying etiology is thought to be based on an exaggerated sympathetic stimulation. TLVABS is a considerable differential diagnosis in ACS, especially in postmenopausal women with a preceding stressful event. Data on longterm follow-up is pending and further studies will be necessary to clarify the etiology and reach consensus in acute and longterm management of TLVABS.