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Correspondence |

Tako-Tsubo Cardiomyopathy and Drowning Syndrome: Is There a Link? FREE TO VIEW

Rodolfo Citro, MD; Mario Previtali, MD; Eduardo Bossone, MD, PhD, FCCP
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Affiliations: San Luca Hospital, Salerno, Italy,  Poloclinico San Matteo Istituto di Ricovero e Cura a Carattere Scientifico, Pavia, Italy,  University of Milan, Milan, Italy

Correspondence to: Rodolfo Citro, MD, San Luca Hospital, Cardiology, via F. Cammarota Vallo della Lucania, Salerno 84048, Italy; e-mail: rodolfocitro@tele2.it



Chest. 2008;134(2):469. doi:10.1378/chest.08-0541
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To the Editor:

We read with great interest the recent article in CHEST (September 2007) on tako-tsubo cardiomyopathy (TTC) by Kurowski et al1and would like to congratulate the authors for their elegant study. In 35 patients with TTC, they reported the occurrence of emotional stress events in 15 patients (42.8%) including a case of near-drowning syndrome (NDS). In our clinical series2 of 52 patients (51 women; mean [± SD] age, 63.58 ± 10.55 years), an emotional stress event was documented in 43.2%. We also registered a 57-year-old woman presenting with TTC after the occurrence of NDS.2A few hours after the event, ECG changes developed, and a typical echocardiographic pattern of apical ballooning with a mild increase in serum troponin level was seen. Left ventriculography confirmed the apical ballooning, and coronary angiography revealed normal coronary arteries. ECG changes and apical contraction abnormalities were completely reversed within 3 weeks. Drowning is an extremely stressful situation that leads, via the uncommon combinations of different pathophysiologic mechanisms, to sympathetic nerve activation (SNA).3 In patients with NDS, submersion in liquid causes hypoxemia due to fluid aspiration or reflexive laryngospasm. Once hypoxemia occurs, cerebral hypoxia, pulmonary reflexes, and concomitant panic and/or struggle induce SNA.3Hypoxemia related to NDS could have induced transient myocardial dysfunction mediated by an SNA. Although the pathogenesis of TTC remains unclear, a common pathophysiologic pathway seems to be an exaggerated sympathetic activation.4 Thus, SNA could be considered the “real” link between NDS and TTC.

From a clinical point of view, it should kept in mind that prolonged but reversible anterior-apical contraction abnormalities without significant coronary artery disease may also occur in critically ill patients who have been hospitalized because of a wide variety of primary noncardiac illnesses (ie, neurogenic myocardial stunning).5 NDS should therefore be added to the already long list of stressful conditions that can lead to the development of TTC.4 Patients surviving the drowning represent a very interesting and challenging population with potential severe cardiac complications, including malignant arrhythmias and myocardial dysfunction. Thus, in the critical care setting, careful monitoring is needed in order to implement the appropriate diagnostic and therapeutic interventions.

The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Kurowski, V, Kaiser, A, von Hof, K, et al (2007) Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency mechanisms, and prognosis.Chest132,809-816. [PubMed] [CrossRef]
 
Citro, R, Patella, MM, Bossone, E, et al Near-drowning syndrome: a possible trigger of tako-tsubo cardiomyopathy.J Cardiovasc Med (Hagerstown)2008;9,501-505. [PubMed]
 
Weinstein, MD, Krieger, BP Near-drowning: epidemiology, pathophysiology, and initial treatment.J Emerg Med1996;14,461-467. [PubMed]
 
Gianni, M, Dentali, F, Grandi, AM, et al Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review.Eur Heart J2006;27,1523-1529. [PubMed]
 
Sharkey, SW, Shear, W, Hodges, M, et al Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest1998;114,98-105. [PubMed]
 

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References

Kurowski, V, Kaiser, A, von Hof, K, et al (2007) Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency mechanisms, and prognosis.Chest132,809-816. [PubMed] [CrossRef]
 
Citro, R, Patella, MM, Bossone, E, et al Near-drowning syndrome: a possible trigger of tako-tsubo cardiomyopathy.J Cardiovasc Med (Hagerstown)2008;9,501-505. [PubMed]
 
Weinstein, MD, Krieger, BP Near-drowning: epidemiology, pathophysiology, and initial treatment.J Emerg Med1996;14,461-467. [PubMed]
 
Gianni, M, Dentali, F, Grandi, AM, et al Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review.Eur Heart J2006;27,1523-1529. [PubMed]
 
Sharkey, SW, Shear, W, Hodges, M, et al Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness.Chest1998;114,98-105. [PubMed]
 
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