Acute Subarachnoid Hemorrhage and Cardiac Abnormalities: Takotsubo Cardiomyopathy or Neurogenic Stunned Myocardium? a case report

Abstract Introduction Cardiac abnormalities can be seen with subarachnoid hemorrhage. To date, there have been isolated case reports of transient left ventricular apical ballooning cardiomyopathy, also known as Takotsubo cardiomyopathy in patients suffering from subarachnoid hemorrhage. Case presentation An adult female was brought to the emergency department with somnolence. A 3 × 3 mm ruptured basilar aneurysm was found and successfully embolized. Two days after the patient developed acute heart failure. Troponin-I was elevated to 4.2 (normal \u3c0.4). On ECG, new symmetric T wave inversion in V3, V4, V5 with prolonged QT were evident. Transthoracic echocardiogram showed severe systolic dysfunction with an ejection fraction of 20% and akinetic apex along with the distal left ventricular segments, consistent with Takotsubo cardiomyopathy. Myocardial contrast echocardiography showed a decrease in capillary blood flow and volume in the akinetic areas with delayed contrast replenishment, sparing the basal segments. A repeat study 2 weeks later showed near normalization of the perfusion parameters. The patient improved with medical management. A repeat echocardiogram, a month later revealed an ejection fraction of 45% with no identifiable wall motion abnormality. Conclusion Our case, as well as others reported previously, supports the diagnosis of Takotsubo cardiomyopathy in patients with Subarachnoid Hemorrhage who fulfill the clinical and imaging description of this syndrome

Predictors for Restoration of Normal Left Ventricular Function in Response to Cardiac Resynchronization Therapy Measured at Time of Implantation.

There are no parameters predicting the individual probability of "full response" to cardiac resynchronization therapy (CRT). The aim of this work was to find prognostic factors of full clinical and echocardiographic responses (i.e., 6550\% left ventricular ejection fraction [LVEF] and New York Heart Association class I) after 1 year of CRT. This was a prospective follow-up study that involved 2 hospitals. Patients (n = 75) with advanced heart failure (64 \ub1 9 years of age, 87\% men, LVEF 24 \ub1 7\%) who received CRT were followed for 17 \ub1 9 months. Univariate and multivariate regression analyses were used to identify predictors of full CRT response. A nomogram predicting the individual probability of full CRT response during follow-up was calculated. There were 13 patients with restoration of normal LVEF versus 62 without (mean LVEF 56\% \ub1 5\% vs 31\% \ub1 8\%, respectively, p 75\% probability of restoration of normal LVEF. In conclusion, our nomogram using a combination of cause, baseline QRS width, and degree of QRS shortening in response to CRT allows assessment of individual probability of full response. This observation awaits further confirmation from larger series

How Can Optimization of Medical Treatment Avoid Unnecessary Implantable Cardioverter-Defibrillator Implantations in Patients With Idiopathic Dilated Cardiomyopathy Presenting With "SCD-HeFT Criteria?"

To assess the proportion and long-term outcomes of patients with idiopathic dilated cardiomyopathy and potential indications for implantable cardioverter-defibrillator before and after optimization of medical treatment, 503 consecutive patients with idiopathic dilated cardiomyopathy were evaluated from 1988 to 2006. A total of 245 patients (49\%) satisfied the "Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) criteria," defined as a left ventricular ejection fraction of 640.35 and New York Heart Association (NYHA) class II-III on registration. Among these, 162 (group A) were re-evaluated 5.4 \ub1 2 months later with concurrent \u3b2-blockers and angiotensin-converting enzyme inhibitor use. Of the 162 patients, 50 (31\%) still had "SCD-HeFT criteria" (group A1), 109 (67\%) had an improved left ventricular ejection fraction and/or New York Heart Association class (group A2), and 3 (2\%) were in NYHA class IV. Of the 227 patients without baseline "SCD-HeFT criteria" (left ventricular ejection fraction >0.35 or NYHA class I), 125 were evaluated after 5.5 \ub1 2 months. Of these 227 patients, 13 (10\%) developed "SCD-HeFT criteria" (group B1), 111 (89\%) remained without "SCD-HeFT criteria" (group B2), and 1 (1\%) had worsened to NYHA class IV. The 10-year mortality/heart transplantation and sudden death/sustained ventricular arrhythmia rate was 57\% and 37\% in group A1, 23\% and 20\% in group A2 (p <0.001 for mortality/heart transplantation and p = 0.014 for sudden death/sustained ventricular arrhythmia vs group A1), 45\% and 41\% in group B1 (p = NS vs group A1), 16\% and 14\% in group B2 (p = NS vs group A2), respectively. In conclusion, two thirds of patients with idiopathic dilated cardiomyopathy and "SCD-HeFT criteria" at presentation did not maintain implantable cardioverter-defibrillator indications 3 to 9 months later with optimal medical therapy. Their long-term outcome was excellent, similar to that observed for patients who had never met the "SCD-HeFT criteria.

If heart failure or cardiac arrest complicate pregnancy and delivery

Physiological adaptation to pregnancy exposes mother's cardiovascular system to relevant hemodynamic overload. These changes and other specific conditions of pregnancy, such as amniotic embolism, can point out unrecognized preexisting heart disease or, in the presence of some cofactors, be burdensome even for healthy hearts. Thus, tragic cases of heart failure or cardiac arrest may occur, whose management requires several considerations with respect of trying to save two lives at the same time, the need for drugs potentially harmful to the fetus, and assessment of emergent cesarean section

Chapter 12: Prognostic Stratification and Importance of Follow-Up

In the last decades, long-term survival of patients affected by dilated cardiomyopathy (DCM) has been markedly improved. The main milestones, such as the early diagnosis and the systematic follow-up, the proper etiological characterization at the onset of the disease, and a multidisciplinary approach to the patients together with the optimal medical and device treatment and the rigorous tailored follow-up, accompanied these prognostic improvements. However, DCM still remains the most common cause of heart transplantation and one of the leading causes of cardiac death in the western world. Therefore, proper prognostic stratification and systematic follow-up are the cornerstones to optimize medical management and improve outcomes of patients with DCM