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"Reverse McConnell's Sign": Interpreting Interventricular Hemodynamic Dependency and Guiding the Management of Acute Heart Failure during Takotsubo Cardiomyopathy.

Liu K, Sun Z, Wei T - Clin Med Insights Cardiol (2015)

Bottom Line: Bedside clinicians often have a diagnostic dilemma when cardiac catheterization and angiography are either contraindicated or can cause potential adverse consequences.Misdiagnosing TTC as AMI will lead to initiation of harmful pharmacological or device-based treatment, which worsens hemodynamic compromise.Therefore, understanding and interpreting the unique pathophysiological and hemodynamic features of TTC in a better manner becomes crucial to guide effective clinical management of acute heart failure/cardiogenic shock during TTC.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, State University of New York, Upstate Medical University, Syracuse, NY.

ABSTRACT
Although most patients with Takotsubo cardiomyopathy (TTC) have benign clinical course and prognosis, TTC can induce acute heart failure and hemodynamic instability. TTC mimics the clinical features of acute anterior wall myocardial infarction (AMI). Bedside clinicians often have a diagnostic dilemma when cardiac catheterization and angiography are either contraindicated or can cause potential adverse consequences. Misdiagnosing TTC as AMI will lead to initiation of harmful pharmacological or device-based treatment, which worsens hemodynamic compromise. Therefore, understanding and interpreting the unique pathophysiological and hemodynamic features of TTC in a better manner becomes crucial to guide effective clinical management of acute heart failure/cardiogenic shock during TTC. We review recent advances in echocardiographic diagnosis of TTC and its role in guiding bedside management of acute heart failure and cardiogenic shock, with specific focus on the interpretation of discrepant, but reciprocally dependent, left and right ventricular hemodynamics during acute stages of TTC.

No MeSH data available.


Related in: MedlinePlus

Different myocardial deformation/strain measurements in patients with AMI and TTC. Left panels: AMI; right panels: TTC. Two-dimensional (2D) strain and speckle-tracking analysis shows peak systolic longitudinal strain in a 17-segment LV model (A and C); four-dimensional (4D) strain technique shows the real-time area strain patterns in a 17-segment LV model (B and D). The walls with decreased peak systolic strain are highlighted by both digital and color codes.
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f3-cmc-suppl.1-2015-033: Different myocardial deformation/strain measurements in patients with AMI and TTC. Left panels: AMI; right panels: TTC. Two-dimensional (2D) strain and speckle-tracking analysis shows peak systolic longitudinal strain in a 17-segment LV model (A and C); four-dimensional (4D) strain technique shows the real-time area strain patterns in a 17-segment LV model (B and D). The walls with decreased peak systolic strain are highlighted by both digital and color codes.

Mentions: Strain/strain rate echocardiography can add more diagnostic value to the differentiation of AMI and TTC. Strain/strain rate analysis assesses myocardial deformation directly, which is independent of not only volume but also myocardial tethering or translational effects. Thus, 2D strain with speckle-tracking analysis automatically tracks myocardial motion throughout the cardiac cycle and allows the rapid generation of regional myocardial strain curves that are site specific and angle independent.18 This technique quantifies ventricular radial, circumferential, and longitudinal strains. Systolic peak longitudinal strain has been proven to deliver reproducible and quantitative ventricular segmental and global assessments, resulting in incremental increase in sensitivity, specificity, and diagnostic accuracy during the evaluation of abnormal subclinical myocardial contractility.19,20 An automated function imaging (AFI) based on 2D strain with speckle-tracking analysis can integrate LV peak systolic longitudinal strain into a “bulls-eye” figure in a standard 17-segment LV model, thus being especially useful in the identification of different patterns of regional contractile abnormality between AMI and TTC (Fig. 3A and C.10,21). The recently developed four-dimensional (4D) strain technique uses a robust postprocessing tool to track myocardial contractility from frame to frame in three dimensions over time and further improves the diagnostic accuracy of strain techniques (Fig. 3B and D). Using the new-generation echocardiography machines, bedside physicians are able to rapidly perform area strain analysis and process AFI maps, either online or offline, to establish the “real” distinctive myocardial deformation curves through the entire cardiac cycle in both TTC and AMI.


"Reverse McConnell's Sign": Interpreting Interventricular Hemodynamic Dependency and Guiding the Management of Acute Heart Failure during Takotsubo Cardiomyopathy.

Liu K, Sun Z, Wei T - Clin Med Insights Cardiol (2015)

Different myocardial deformation/strain measurements in patients with AMI and TTC. Left panels: AMI; right panels: TTC. Two-dimensional (2D) strain and speckle-tracking analysis shows peak systolic longitudinal strain in a 17-segment LV model (A and C); four-dimensional (4D) strain technique shows the real-time area strain patterns in a 17-segment LV model (B and D). The walls with decreased peak systolic strain are highlighted by both digital and color codes.
© Copyright Policy - open-access
Related In: Results  -  Collection

Show All Figures
getmorefigures.php?uid=PMC4373721&req=5

f3-cmc-suppl.1-2015-033: Different myocardial deformation/strain measurements in patients with AMI and TTC. Left panels: AMI; right panels: TTC. Two-dimensional (2D) strain and speckle-tracking analysis shows peak systolic longitudinal strain in a 17-segment LV model (A and C); four-dimensional (4D) strain technique shows the real-time area strain patterns in a 17-segment LV model (B and D). The walls with decreased peak systolic strain are highlighted by both digital and color codes.
Mentions: Strain/strain rate echocardiography can add more diagnostic value to the differentiation of AMI and TTC. Strain/strain rate analysis assesses myocardial deformation directly, which is independent of not only volume but also myocardial tethering or translational effects. Thus, 2D strain with speckle-tracking analysis automatically tracks myocardial motion throughout the cardiac cycle and allows the rapid generation of regional myocardial strain curves that are site specific and angle independent.18 This technique quantifies ventricular radial, circumferential, and longitudinal strains. Systolic peak longitudinal strain has been proven to deliver reproducible and quantitative ventricular segmental and global assessments, resulting in incremental increase in sensitivity, specificity, and diagnostic accuracy during the evaluation of abnormal subclinical myocardial contractility.19,20 An automated function imaging (AFI) based on 2D strain with speckle-tracking analysis can integrate LV peak systolic longitudinal strain into a “bulls-eye” figure in a standard 17-segment LV model, thus being especially useful in the identification of different patterns of regional contractile abnormality between AMI and TTC (Fig. 3A and C.10,21). The recently developed four-dimensional (4D) strain technique uses a robust postprocessing tool to track myocardial contractility from frame to frame in three dimensions over time and further improves the diagnostic accuracy of strain techniques (Fig. 3B and D). Using the new-generation echocardiography machines, bedside physicians are able to rapidly perform area strain analysis and process AFI maps, either online or offline, to establish the “real” distinctive myocardial deformation curves through the entire cardiac cycle in both TTC and AMI.

Bottom Line: Bedside clinicians often have a diagnostic dilemma when cardiac catheterization and angiography are either contraindicated or can cause potential adverse consequences.Misdiagnosing TTC as AMI will lead to initiation of harmful pharmacological or device-based treatment, which worsens hemodynamic compromise.Therefore, understanding and interpreting the unique pathophysiological and hemodynamic features of TTC in a better manner becomes crucial to guide effective clinical management of acute heart failure/cardiogenic shock during TTC.

View Article: PubMed Central - PubMed

Affiliation: Department of Medicine, State University of New York, Upstate Medical University, Syracuse, NY.

ABSTRACT
Although most patients with Takotsubo cardiomyopathy (TTC) have benign clinical course and prognosis, TTC can induce acute heart failure and hemodynamic instability. TTC mimics the clinical features of acute anterior wall myocardial infarction (AMI). Bedside clinicians often have a diagnostic dilemma when cardiac catheterization and angiography are either contraindicated or can cause potential adverse consequences. Misdiagnosing TTC as AMI will lead to initiation of harmful pharmacological or device-based treatment, which worsens hemodynamic compromise. Therefore, understanding and interpreting the unique pathophysiological and hemodynamic features of TTC in a better manner becomes crucial to guide effective clinical management of acute heart failure/cardiogenic shock during TTC. We review recent advances in echocardiographic diagnosis of TTC and its role in guiding bedside management of acute heart failure and cardiogenic shock, with specific focus on the interpretation of discrepant, but reciprocally dependent, left and right ventricular hemodynamics during acute stages of TTC.

No MeSH data available.


Related in: MedlinePlus