Chandrasegaram Manju D, Celermajer David S, Wilson Michael K
Department of Cardiothoracic Surgery, Royal Prince Alfred Hospital, Sydney, Australia.
J Cardiothorac Surg. 2007 Feb 21;2:14. doi: 10.1186/1749-8090-2-14.
Apical ballooning syndrome (or Takotsubo cardiomyopathy) is a syndrome of transient left ventricular apical ballooning. Although first described in Japanese patients, it is now well reported in the Caucasian population. The syndrome mimicks an acute myocardial infarction but is characterised by the absence of obstructive coronary disease. We describe a serious and poorly understood complication of Takotsubo cardiomyopathy.
We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarction. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. It was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect. Echocardiogram revealed severe mitral regurgitation, left ventricular apical ballooning, and systolic anterior motion of the mitral valve with significant left ventricular outflow tract gradient (60-70 mmHg). Coronary angiography revealed no obstructive coronary lesions.She had an intra-aortic balloon pump inserted with no improvement in her parlous haemodynamic state. We elected to replace her mitral valve to correct the outflow tract gradient and mitral regurgitation. Intra-operatively the mitral valve was mildly myxomatous but there were no structural abnormalities. She had a mechanical mitral valve replacement with a 29 mm St Jude valve. Post-operatively, her left ventricular outflow obstruction resolved and ventricular function returned to normal over the subsequent 10 days. She recovered well.
This case represents a serious and poorly understood association of Takotsubo cardiomyopathy with acute pulmonary oedema, severe mitral regurgitation and systolic anterior motion of the mitral valve with significant left ventricular outflow tract obstruction. The sequence of our patient's presentation suggests that the apical ballooning caused geometric alterations in her left ventricle that in turn led to acute and severe mitral regurgitation, systolic anterior motion of the mitral valve and left ventricular outflow tract obstruction. The left ventricular outflow tract obstruction and mitral regurgitation were corrected by mechanical mitral valve replacement. We describe a variant of Takotsubo cardiomyopathy with acute mitral regurgitation, systolic anterior motion of the mitral valve leaflet and left ventricular outflow tract obstruction of a dynamic nature.
心尖球囊综合征（或应激性心肌病）是一种左心室心尖部短暂球囊样扩张的综合征。尽管最初是在日本患者中描述的，但现在在白种人群中也有大量报道。该综合征类似急性心肌梗死，但特征是不存在阻塞性冠状动脉疾病。我们描述了一种应激性心肌病严重且鲜为人知的并发症。
我们报告一例65岁女性患者，她从一家乡村医院转诊至我院，在那家医院她因疑似急性前壁心肌梗死接受了溶栓治疗。溶栓后4小时，她出现了急性肺水肿和新的收缩期杂音。推测她患有继发于乳头肌破裂、缺血性功能障碍或急性室间隔缺损的急性二尖瓣反流。超声心动图显示严重二尖瓣反流、左心室心尖部球囊样扩张、二尖瓣收缩期前向运动以及显著的左心室流出道压差（60 - 70 mmHg）。冠状动脉造影显示无阻塞性冠状动脉病变。她植入了主动脉内球囊反搏，但危险的血流动力学状态并无改善。我们决定置换她的二尖瓣以纠正流出道压差和二尖瓣反流。术中二尖瓣轻度黏液瘤样变，但无结构异常。她接受了一枚29 mm的圣犹达机械二尖瓣置换术。术后，她的左心室流出道梗阻解除，心室功能在随后10天恢复正常。她恢复良好。
该病例代表了应激性心肌病与急性肺水肿、严重二尖瓣反流、二尖瓣收缩期前向运动以及显著左心室流出道梗阻之间一种严重且鲜为人知的关联。我们患者的临床表现顺序提示，心尖部球囊样扩张导致其左心室几何形态改变，进而导致急性严重二尖瓣反流、二尖瓣收缩期前向运动和左心室流出道梗阻。通过机械二尖瓣置换术纠正了左心室流出道梗阻和二尖瓣反流。我们描述了一种伴有急性二尖瓣反流、二尖瓣叶收缩期前向运动和动态性左心室流出道梗阻的应激性心肌病变体。
