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Can takotsubo cardiomyopathy be diagnosed by autopsy? Report of a presumed case presenting as cardiac rupture

View Article: PubMed Central - PubMed

ABSTRACT

Background: Takostsubo (stress) cardiomyopathy (TC) is a clinical syndrome featuring transient left ventricular dysfunction and wall-motion abnormalities, usually following emotional or physical stress. The diagnosis of TC depends on fulfillment of multiple clinical criteria. Although the pathogenesis has not been firmly established, myocardial cathecholamine toxicity is thought to represent a primary mechanism.

Background: The vast majority of patients with TC survive. However, a rare cause of death in TC is myocardial rupture. All documented cases of rupture have followed known, recently diagnosed or suspected TC. However, in this report we propose that an initial diagnosis of TC with myocardial rupture can be made by autopsy when supported by a compelling clinical history and appropriate histologic changes in the myocardium.

Case presentation: An 82 year-old female underwent elective craniotomy for a recently discovered craniopharyngioma. The surgery was uneventful; the initial postoperative course featured diabetes insipidus and delirium. With no prior warning, on the third postoperative day she was found unresponsive in bed. Two prolonged cardiopulmonary resuscitations were successful, however, during a third arrest maneuvers were stopped at the request of the family. An autopsy was conducted which revealed hemopericardium due to cardiac rupture. Coronary artery atherosclerosis, valve disease, and renal and extra-renal pheochromocytoma were absent. Microscopy of the myocardium showed a recent, localized, transmural myocardial infarction and diffuse changes (all four ventricles) typical of cathecholamine cardiomyopathy. The findings were considered compatible with TC with secondary myocardial rupture.

Conclusion: An initial diagnosis of TC with myocardial rupture can be reasonably made by autopsy in the context of an appropriate clinical history and the presence of the characteristic microscopic features of cathecholamine excess in the myocardium.

No MeSH data available.


Related in: MedlinePlus

Microscopic features of the uninfarcted heart. a, b, c Medium power views showing interstitial edema with mononuclear cell infiltrates. d, e, f High power views of the mononuclear interstitial infiltrates. Rare polymorphonuclear leukocytes and eosinophils are present
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Fig2: Microscopic features of the uninfarcted heart. a, b, c Medium power views showing interstitial edema with mononuclear cell infiltrates. d, e, f High power views of the mononuclear interstitial infiltrates. Rare polymorphonuclear leukocytes and eosinophils are present

Mentions: Microscopic examination of sections from the rupture site showed epicardial hemorrhage and contraction band necrosis with heavy polymorphonuclear leukocyte infiltrates typical of a recent acute myocardial infarction, approximately 48–72 h [10] (Fig. 1b). The unusual site of the rupture, the absence of macroscopic features of an associated myocardial infarction, and the entire absence of coronary artery vascular disease, provoked a thorough examination of the rest of the myocardium. All thirty-four sections of grossly normal myocardium from the left and right ventricules revealed the following microscopic changes: areas of interstitial edema with patchy mononuclear cell infiltrates of lymphocytes and macrophages, and rare polymorphonuclear leukocytes, mast cells and eosinophils. These were found within the myocardium and also around intra-myocardial blood vessels (Fig. 2). There was no evidence of myocardial fibrosis. As these modifications involved the left and right ventricules diffusely, there was no correlation with the territory of an individual coronary artery. The findings were considered compatible with cathecholamine cardiomyopathy. The final autopsy diagnosis was of takotsubo cardiomyopathy with secondary myocardial rupture.Fig. 2


Can takotsubo cardiomyopathy be diagnosed by autopsy? Report of a presumed case presenting as cardiac rupture
Microscopic features of the uninfarcted heart. a, b, c Medium power views showing interstitial edema with mononuclear cell infiltrates. d, e, f High power views of the mononuclear interstitial infiltrates. Rare polymorphonuclear leukocytes and eosinophils are present
© Copyright Policy - OpenAccess
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC5382367&req=5

Fig2: Microscopic features of the uninfarcted heart. a, b, c Medium power views showing interstitial edema with mononuclear cell infiltrates. d, e, f High power views of the mononuclear interstitial infiltrates. Rare polymorphonuclear leukocytes and eosinophils are present
Mentions: Microscopic examination of sections from the rupture site showed epicardial hemorrhage and contraction band necrosis with heavy polymorphonuclear leukocyte infiltrates typical of a recent acute myocardial infarction, approximately 48–72 h [10] (Fig. 1b). The unusual site of the rupture, the absence of macroscopic features of an associated myocardial infarction, and the entire absence of coronary artery vascular disease, provoked a thorough examination of the rest of the myocardium. All thirty-four sections of grossly normal myocardium from the left and right ventricules revealed the following microscopic changes: areas of interstitial edema with patchy mononuclear cell infiltrates of lymphocytes and macrophages, and rare polymorphonuclear leukocytes, mast cells and eosinophils. These were found within the myocardium and also around intra-myocardial blood vessels (Fig. 2). There was no evidence of myocardial fibrosis. As these modifications involved the left and right ventricules diffusely, there was no correlation with the territory of an individual coronary artery. The findings were considered compatible with cathecholamine cardiomyopathy. The final autopsy diagnosis was of takotsubo cardiomyopathy with secondary myocardial rupture.Fig. 2

View Article: PubMed Central - PubMed

ABSTRACT

Background: Takostsubo (stress) cardiomyopathy (TC) is a clinical syndrome featuring transient left ventricular dysfunction and wall-motion abnormalities, usually following emotional or physical stress. The diagnosis of TC depends on fulfillment of multiple clinical criteria. Although the pathogenesis has not been firmly established, myocardial cathecholamine toxicity is thought to represent a primary mechanism.

Background: The vast majority of patients with TC survive. However, a rare cause of death in TC is myocardial rupture. All documented cases of rupture have followed known, recently diagnosed or suspected TC. However, in this report we propose that an initial diagnosis of TC with myocardial rupture can be made by autopsy when supported by a compelling clinical history and appropriate histologic changes in the myocardium.

Case presentation: An 82 year-old female underwent elective craniotomy for a recently discovered craniopharyngioma. The surgery was uneventful; the initial postoperative course featured diabetes insipidus and delirium. With no prior warning, on the third postoperative day she was found unresponsive in bed. Two prolonged cardiopulmonary resuscitations were successful, however, during a third arrest maneuvers were stopped at the request of the family. An autopsy was conducted which revealed hemopericardium due to cardiac rupture. Coronary artery atherosclerosis, valve disease, and renal and extra-renal pheochromocytoma were absent. Microscopy of the myocardium showed a recent, localized, transmural myocardial infarction and diffuse changes (all four ventricles) typical of cathecholamine cardiomyopathy. The findings were considered compatible with TC with secondary myocardial rupture.

Conclusion: An initial diagnosis of TC with myocardial rupture can be reasonably made by autopsy in the context of an appropriate clinical history and the presence of the characteristic microscopic features of cathecholamine excess in the myocardium.

No MeSH data available.


Related in: MedlinePlus