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Catecholamine cardiomyopathy
 
Published on 2015-12-07 by Walid Gharzuddine
 
 
History and Findings
 

A 44 year old female was transferred from a primary care hospital where she had been admitted with symptoms of epigastric pain and dyspnea that progressed dramatically to respiratory failure and a picture of pulmonary edema. Emergency coronary angiography was performed which revealed patent coronary arteries with LV angiography (video 3) and echocardiography (videos1&2)  showing severe hypokinesis of basal and mid-ventricular segments of the left ventricle.  The diagnosis of stress induced (catecholamine) cardiomyopathy was hence considered with the wall motion pattern consistent with the term “reverse tako tsubo” since the classical form of tako tsubo involves apical ballooning with hyperkinesis of the mid and basal ventricular segments. Of interest was the appearance of the left ventricle on global longitudinal strain (figure 1) with the red area representing normal contractility in the apex and gradual transformation into the blue dysfunctional basal segments.

The patient’s condition deteriorated and she ultimately required mechanical circulatory support with extra-corporeal membrane oxygenation (ECMO). Serial echocardiography showed gradual recovery of her left ventricular function (video 4) and it was possible to discontinue the hemodynamic assist device. During the course of her illness she was found on CT imaging to have a suprarenal gland tumor and laboratory tests showed a marked elevation of serum and urine metanephrines  which are highly in favor of the diagnosis of pheochromocytoma.

Although her cardiac status showed full recovery she is still under treatment for respiratory and neuromuscular complications of the illness and hence has not undergone surgical excision of the mass which would conclusively rule in or out this diagnosis.

 
 
 
1. Apical 4 chamber | Apical 2 chamber | 3. LV angiography | Recovery apical 4 ch,.
 
 
 
 
 
Discussion
 

According to Mayo clinic criteria (ref. 1) the definition of tako tsubo cardiomyopathy should be made when the following conditions are excluded: Absence of recent significant head trauma, intracranial bleeding, pheochromocytoma, myocarditis and hypertrophic cardiomyopathy. However all these conditions would fall under the broader term catecholamine induced cardiomyopathy.

 

 In a recent review of 1750 patients with takotsubo cardiomyopathy the condition was classified as one of the following types based on transthoracic echocardiography and/or left ventricular angiography: (reference 3)

Apical Type. This type is characterized by hypo-, a- or dyskinesia of midventricular and apical parts of the anterior, septal, inferior and lateral wall of the left ventricle, associated with hyperkinesia of basal segments.

Midventricular Type. This type comprises hypo-, a- or dyskinesia of midventricular segments, most often like a cuff, with normo- or hyperkinesia of basal and apical segments.

Basal Type. This type involves hypo-, a- or dyskinesia of basal segments and normo- or hyperkinesia of midventricular and anterior, anteroseptal and/or anteroapikal segments of the left ventricle. In this the basal type shows wall-motion abnormalities complementary to the apical type, as such the basal type is also referred to as “inverse” form of takotsubo cardiomyopathy.

Focal Type. This type is characterized by focal hypo-, a- or dyskinesia of any segment of the left ventricle. In most cases an anterolateral segment is involved.

Apical takotsubo cardiomyopathy was identified in 81.7% of patients, whereas the midventricular form was found in 14.6%, and basal and focal forms were diagnosed in 2.2% and 1.5%, respectively.

1571 (89.8%) were women (mean [±SD] age, 66.8±13.0 years), and 1384 of all patients (79.1%) were women older than 50 years of age.

In conclusion the presentation and clinical course of this patient are in favor of the diagnosis of a catecholamine induced cardiomyopathy of the mixed mid and basal ventricular types probably related to a pheochromocytoma. (ref. 3)

 

References:

 

1.Yoshihiro J. Akashi, David S. Goldstein, Giuseppe Barbaro and Takashi Ueyama Takotsubo Cardiomyopathy : A New Form of Acute, Reversible Heart Failure.  Circulation. 2008;118:2754-2762

 2. C. Templin, J.R. Ghadri, J. Diekmann, L.C. Napp, D.R. Bataiosu et al. Clinical features and outcomes of tako tsubo cardiomyopathy New Engl J Med 2015;373:929-38.


3. Thaslim Ahamed Kassim, MD.  Douglas D. Clarke, DO, Vinh Q. Mai, DO, Patrick W. Clyde, MD, FACP, FACE, 
and K. M. Mohamed Shakir, MD, MACP, MACE, FRCP, FACN CATECHOLAMINE-INDUCED CARDIOMYOPATHY Endocr Pract. 2008;14:1137- 1149.

 
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