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Apical ballooning syndrome complicated by acute severe mitral regurgitation with left ventricular outflow obstruction--case report.

Chandrasegaram MD, Celermajer DS, Wilson MK - J Cardiothorac Surg (2007)

Bottom Line: Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60-70 mmHg).She recovered well.The left ventricular outflow tract obstruction and mitral regurgitation were corrected by mechanical mitral valve replacement.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia. manjudashini@yahoo.com

ABSTRACT

Background: Apical ballooning syndrome (or Takotsubo cardiomyopathy) is a syndrome of transient left ventricular apical ballooning. Although first described in Japanese patients, it is now well reported in the Caucasian population. The syndrome mimicks an acute myocardial infarction but is characterised by the absence of obstructive coronary disease. We describe a serious and poorly understood complication of Takotsubo cardiomyopathy.

Case presentation: We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. It was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect. Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60-70 mmHg). Coronary angiography revealed no obstructive coronary lesions.She had an intra-aortic balloon pump inserted with no improvement in her parlous haemodynamic state. We elected to replace her mitral valve to correct the outflow tract gradient and mitral regurgitation. Intra-operatively the mitral valve was mildly myxomatous but there were no structural abnormalities. She had a mechanical mitral valve replacement with a 29 mm St Jude valve. Post-operatively, her left ventricular outflow obstruction resolved and ventricular function returned to normal over the subsequent 10 days. She recovered well.

Conclusion: This case represents a serious and poorly understood association of Takotsubo cardiomyopathy with acute pulmonary oedema, severe mitral regurgitation and systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction. The sequence of our patient's presentation suggests that the apical ballooning caused geometric alterations in her left ventricle that in turn led to acute and severe mitral regurgitation, systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction. The left ventricular outflow tract obstruction and mitral regurgitation were corrected by mechanical mitral valve replacement. We describe a variant of Takotsubo cardiomyopathy with acute mitral regurgitation, systolic anterior motion of the mitral valve leaflet and left ventricular outflow tract obstruction of a dynamic nature.

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Mitral regurgitation.
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Figure 1: Mitral regurgitation.

Mentions: She was transferred on heparin and glyceryl trinitrate infusion, in acute pulmonary oedema (confirmed by chest X-ray), with a systolic blood pressure of 110 mmHg, and heart rate of 130/minute. Urgent echocardiogram showed severe mitral regurgitation (see Figure 1). Her mitral valve annulus was slightly widened at 3.2 cm and subvalvular structures were intact. She also had left ventricular apical ballooning (LVAB) and systolic anterior motion (SAM) of the mitral valve leaflet with septal contact – left ventricular outflow tract gradient (LVOT) 60–70 mmHg (see Figures 2 and 3). Coronary angiography fourteen hours after her presentation showed no obstructive coronary lesions. Ventriculogram revealed akinesis of the anterolateral wall and apex of her left ventricle, more extensive than any single coronary territory, and grade 4/4 mitral regurgitation (see Figures 4 and 5).


Apical ballooning syndrome complicated by acute severe mitral regurgitation with left ventricular outflow obstruction--case report.

Chandrasegaram MD, Celermajer DS, Wilson MK - J Cardiothorac Surg (2007)

Mitral regurgitation.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC1804269&req=5

Figure 1: Mitral regurgitation.
Mentions: She was transferred on heparin and glyceryl trinitrate infusion, in acute pulmonary oedema (confirmed by chest X-ray), with a systolic blood pressure of 110 mmHg, and heart rate of 130/minute. Urgent echocardiogram showed severe mitral regurgitation (see Figure 1). Her mitral valve annulus was slightly widened at 3.2 cm and subvalvular structures were intact. She also had left ventricular apical ballooning (LVAB) and systolic anterior motion (SAM) of the mitral valve leaflet with septal contact – left ventricular outflow tract gradient (LVOT) 60–70 mmHg (see Figures 2 and 3). Coronary angiography fourteen hours after her presentation showed no obstructive coronary lesions. Ventriculogram revealed akinesis of the anterolateral wall and apex of her left ventricle, more extensive than any single coronary territory, and grade 4/4 mitral regurgitation (see Figures 4 and 5).

Bottom Line: Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60-70 mmHg).She recovered well.The left ventricular outflow tract obstruction and mitral regurgitation were corrected by mechanical mitral valve replacement.

View Article: PubMed Central - HTML - PubMed

Affiliation: Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia. manjudashini@yahoo.com

ABSTRACT

Background: Apical ballooning syndrome (or Takotsubo cardiomyopathy) is a syndrome of transient left ventricular apical ballooning. Although first described in Japanese patients, it is now well reported in the Caucasian population. The syndrome mimicks an acute myocardial infarction but is characterised by the absence of obstructive coronary disease. We describe a serious and poorly understood complication of Takotsubo cardiomyopathy.

Case presentation: We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. It was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect. Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60-70 mmHg). Coronary angiography revealed no obstructive coronary lesions.She had an intra-aortic balloon pump inserted with no improvement in her parlous haemodynamic state. We elected to replace her mitral valve to correct the outflow tract gradient and mitral regurgitation. Intra-operatively the mitral valve was mildly myxomatous but there were no structural abnormalities. She had a mechanical mitral valve replacement with a 29 mm St Jude valve. Post-operatively, her left ventricular outflow obstruction resolved and ventricular function returned to normal over the subsequent 10 days. She recovered well.

Conclusion: This case represents a serious and poorly understood association of Takotsubo cardiomyopathy with acute pulmonary oedema, severe mitral regurgitation and systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction. The sequence of our patient's presentation suggests that the apical ballooning caused geometric alterations in her left ventricle that in turn led to acute and severe mitral regurgitation, systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction. The left ventricular outflow tract obstruction and mitral regurgitation were corrected by mechanical mitral valve replacement. We describe a variant of Takotsubo cardiomyopathy with acute mitral regurgitation, systolic anterior motion of the mitral valve leaflet and left ventricular outflow tract obstruction of a dynamic nature.

Show MeSH
Related in: MedlinePlus