(Tako-Tsubo type cardiomyopathy, stress cardiomyopathy, transient ventricular apical bloating syndrome)

Particular form of acquired and transient stress-related cardiomyopathy. It is close to the acute cardiomyopathy of neurogenic origin observed in case of involvement of the brain structures taking part in the regulation of blood pressure (subarachnoid hemorrhage, trauma or tumor at the level of the brainstem, the hypothalamus or insula): the latter is linked to the massive release of catecholamines at the level of the cardiac sympathetic system 

Tako-Tsubo cardiomyopathy was originally described in women older than 65 years. In reality it can occur at any age. The diagnostic criteria are:

-         hypokinesia, akinesia or transient dyskinesia of the median portion of the left ventricle, with or without apex impairment at the occasion of a stressful event; the LV presents apical ballooning and looks like a round-bottomed vase with a narrow neck which serves as a fishing pot for Octopus in Japan (from which the name of affection)

-         the absence of coronary artery obstruction

-         the presence of abnormal ECG (elevation of the ST segment or inversion of T wave) or elevated cardiac troponin

-         the absence of myocarditis or pheochromocytoma.

The triggering factor is an intense physical or emotional stress.  Pre-and post-operative cases have been described especially after decompression of acute hydrocephalus.

The massive release of catecholamines could thus produce myocardial stunning. The fact that this acute dysfunction is more pronounced at the medio-ventricular level and at the apex could be linked to the rich concentration of  β-2 adrenergetic receptors at this level. Hyperkinesia of the base of the heart aggravates the clinical picture because it reduces ventricular filling.

Symptoms: chest pain, dyspnea, rhythm disturbances, major hypotension, shock, acute pulmonary edema.

Healing is spontaneous in a few hours or days if the complications are treated symptomatically: inotropes, peripheral vasodilators (milrinone, levosimendan).

In case of a similar clinical situation in infants, exclude the diagnosis of abnormal origin of the left coronary artery from the pulmonary artery (ALCAPA, see this term).

Anesthetic implications: 

keep that in mind in case of hypotension, ST segment changes or arrhythmias in the context of  peri - per-anesthetic stress: induction, laryngoscopy, emergence of anestheia, LRA in a  stressed patient... Possible preventive effect of α2 agonists.

References : 

• Biteker M, Duran NE, Civan HA et al. 
  Broken heart syndrome in a 17-year-old girl. 
  Eur J Pediatr 2009 ; 168 : 1273-5
• Johnson J, Ragheb J, Garg R, Patten W et al. 
  Neurogenic stunned myocardium after acute hydrocephalus: report of 2 cases. 
  J Neurosurg Pediatrics 2010; 5: 428-33.
• Nunez FB, Tschiedel E, Felderhoff-Mueser U, Neudorf U et al. 
  Neurogenic stunned myocardium after embolization in two children with vein of Galen aneurysmal malformation. 
  Neuroradiology 2013; 55: 213-6.
• Hessel EA, London MJ. 
  Takotsubo (stress) cardiomyopathy and the anaesthesiologist: enough case reports. Let’s try to answer some specific questions! 
  Anesthesiology 2010; 110: 674-8.
• Baleine J, Jacquot A, Rideau Batista Novais A, Durand S et al. 
  Cardiomyopathie de type tako-tsubo chez une adolescente. 
  Arch Pédiatr 2014  in press
• Mazzeo AT, Micalizzi A, Mascia L, A scicolone A, Siracusano L. 
  Brain-heart crosstalk: the many faces of stress-related cardiomyopathy syndromes in anaesthesia and intensive care. 
  Br J Anaesth 2014, 112: 803-15.

Updated: September 2018