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Incidence and Clinical Impact of Right Ventricular Involvement (Biventricular Ballooning) in Takotsubo Syndrome

Results From the GEIST Registry

      Background

      The short- and long-term prognosis of Takotsubo syndrome (TTS) presenting with right ventricular (RV) involvement remains poorly understood.

      Research Question

      What is the incidence and clinical outcome of RV involvement in TTS?

      Study Design and Methods

      This study analyzed 839 consecutive patients with TTS (758 female subjects and 81 male subjects) in a multicenter registry. RV involvement was defined as wall motion abnormality of the RV free wall, with or without apical involvement. The median long-term follow-up was 2.1 years (interquartile range, 0.3-4.5 years). The primary outcome was in-hospital and out-of-hospital all-cause mortality. The secondary end point was a composite of in-hospital death, thromboembolic events, cardiogenic shock, pulmonary edema, and malignant arrhythmias.

      Results

      The incidence of RV involvement in TTS was 11% (n = 93). More often patients with RV involvement were male compared with patients without RV involvement (P = .02). There was a slight difference in the left ventricular ejection fraction measured in patients with RV involvement vs those patients with isolated left ventricular TTS (38 ± 10% vs 40 ± 10%; P = .03). No major differences in terms of comorbidities were observed between groups except regarding a history of cancer, which was significantly more prevalent in patients with TTS presenting with RV involvement (P = .03). Physical stressors were more prevalent in the RV group (P < .01), whereas emotional stressors were less prevalent (P < .01). Patients with RV involvement had a higher incidence of in-hospital cardiogenic shock (P = .02). The primary outcome (in- and out-of-hospital all-cause mortality) was observed in 12.8% of patients without RV involvement compared with 29% of patients with RV involvement. Although the in-hospital mortality rate was similar in both groups, a higher out-of-hospital all-cause mortality rate (log-rank test, P = .008) was observed in the RV involvement group. The Cox multivariable regression analysis showed that physical triggers were independent predictors of RV involvement.

      Interpretation

      RV involvement defines a high-risk cohort of patients with TTS.

      Clinical Trial Registration

      Key Words

      Abbreviations:

      CMR (cardiac magnetic resonance), HR (hazard ratio), IQR (interquartile range), LV (left ventricular), LVEF (left ventricular ejection fraction), RV (right ventricular), TTS (Takotsubo syndrome)
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      References

        • Dote K.
        • Sato H.
        • Tateishi H.
        • Uchida T.
        • Ishihara M.
        Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases [in Japanese].
        J Cardiol. 1991; 21: 203-214
        • Haghi D.
        • Athanasiadis A.
        • Papavassiliu T.
        • et al.
        Right ventricular involvement in Takotsubo cardiomyopathy.
        Eur Heart J. 2006; 27: 2433-2439
        • Elesber A.A.
        • Prasad A.
        • Bybee K.A.
        • et al.
        Transient cardiac apical ballooning syndrome: prevalence and clinical implications of right ventricular involvement.
        J Am Coll Cardiol. 2006; 47: 1082-1083
        • Borchert T.
        • Hubscher D.
        • Guessoum C.I.
        • et al.
        Catecholamine-dependent beta-adrenergic signaling in a pluripotent stem cell model of Takotsubo cardiomyopathy.
        J Am Coll Cardiol. 2017; 70: 975-991
        • El-Battrawy I.
        • Zhao Z.
        • Lan H.
        • et al.
        Estradiol protection against toxic effects of catecholamine on electrical properties in human-induced pluripotent stem cell derived cardiomyocytes.
        Int J Cardiol. 2018; 254: 195-202
        • Wilson H.M.
        • Cheyne L.
        • Brown P.A.J.
        • et al.
        Characterization of the myocardial inflammatory response in acute stress-induced (Takotsubo) cardiomyopathy.
        JACC Basic Transl Sci. 2018; 3: 766-778
        • Wittstein I.S.
        • Thiemann D.R.
        • Lima J.A.
        • et al.
        Neurohumoral features of myocardial stunning due to sudden emotional stress.
        N Engl J Med. 2005; 352: 539-548
        • Scally C.
        • Abbas H.
        • Ahearn T.
        • et al.
        Myocardial and systemic inflammation in acute stress-induced (Takotsubo) cardiomyopathy.
        Circulation. 2019; 139: 1581-1592
        • Santoro F.
        • Costantino M.D.
        • Guastafierro F.
        • et al.
        Inflammatory patterns in Takotsubo cardiomyopathy and acute coronary syndrome: a propensity score matched analysis.
        Atherosclerosis. 2018; 274: 157-161
        • Finocchiaro G.
        • Kobayashi Y.
        • Magavern E.
        • et al.
        Prevalence and prognostic role of right ventricular involvement in stress-induced cardiomyopathy.
        J Card Fail. 2015; 21: 419-425
        • Citro R.
        • Bossone E.
        • Parodi G.
        • et al.
        Independent impact of RV Involvement on in-hospital outcome of patients with Takotsubo syndrome.
        JACC Cardiovasc Imaging. 2016; 9: 894-895
        • Kagiyama N.
        • Okura H.
        • Tamada T.
        • et al.
        Impact of right ventricular involvement on the prognosis of takotsubo cardiomyopathy.
        Eur Heart J Cardiovasc Imaging. 2016; 17: 210-216
        • Becher T.
        • El-Battrawy I.
        • Baumann S.
        • et al.
        Characteristics and long-term outcome of right ventricular involvement in Takotsubo cardiomyopathy.
        Int J Cardiol. 2016; 220: 371-375
        • Lyon A.R.
        • Bossone E.
        • Schneider B.
        • et al.
        Current state of knowledge on Takotsubo syndrome: a position statement from the Taskforce on Takotsubo Syndrome of the Heart Failure Association of the European Society of Cardiology.
        Eur J Heart Fail. 2016; 18: 8-27
        • Eitel I.
        • von Knobelsdorff-Brenkenhoff F.
        • Bernhardt P.
        • et al.
        Clinical characteristics and cardiovascular magnetic resonance findings in stress (takotsubo) cardiomyopathy.
        JAMA. 2011; 306: 277-286
        • Lee P.H.
        • Song J.K.
        • Sun B.J.
        • et al.
        Outcomes of patients with stress-induced cardiomyopathy diagnosed by echocardiography in a tertiary referral hospital.
        J Am Soc Echocardiogr. 2010; 23: 766-771
        • Ghadri J.R.
        • Wittstein I.S.
        • Prasad A.
        • et al.
        International Expert Consensus Document on Takotsubo Syndrome (Part I): clinical characteristics, diagnostic criteria, and pathophysiology.
        Eur Heart J. 2018; 39: 2032-2046
        • Ghadri J.R.
        • Wittstein I.S.
        • Prasad A.
        • et al.
        International Expert Consensus Document on Takotsubo syndrome (Part II): diagnostic workup, outcome, and management.
        Eur Heart J. 2018; 39: 2047-2062
        • Evangelista A.
        • Flachskampf F.
        • Lancellotti P.
        • et al.
        European Association of Echocardiography recommendations for standardization of performance, digital storage and reporting of echocardiographic studies.
        Eur J Echocardiogr. 2008; 9: 438-448
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        Eur Heart J Cardiovasc Imaging. 2015; 16: 233-270
        • Rudski L.G.
        • Lai W.W.
        • Afilalo J.
        • et al.
        Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography.
        J Am Soc Echocardiogr. 2010; 23 (quiz 786-688): 685-713
      1. National Institutes of Health Clinical Center. The GErman Italian Spanish Takotsubo (GEIST) Registry (GEIST). NCT04361994. ClinicalTrials.gov. National Institutes of Health; 2020. Updated May 12, 2020. https://clinicaltrials.gov/ct2/show/NCT04361994

        • Fitzgibbons T.P.
        • Madias C.
        • Seth A.
        • et al.
        Prevalence and clinical characteristics of right ventricular dysfunction in transient stress cardiomyopathy.
        Am J Cardiol. 2009; 104: 133-136
        • Stiermaier T.
        • Lange T.
        • Chiribiri A.
        • et al.
        Right ventricular strain assessment by cardiovascular magnetic resonance myocardial feature tracking allows optimized risk stratification in Takotsubo syndrome.
        PLoS One. 2018; 13e0202146
        • Schneider B.
        • Athanasiadis A.
        • Schwab J.
        • et al.
        Complications in the clinical course of tako-tsubo cardiomyopathy.
        Int J Cardiol. 2014; 176: 199-205
        • Stiermaier T.
        • Eitel C.
        • Desch S.
        • et al.
        Incidence, determinants and prognostic relevance of cardiogenic shock in patients with Takotsubo cardiomyopathy.
        Eur Heart J Acute Cardiovasc Care. 2016; 5: 489-496
        • Barbieri A.
        • Bimonte S.
        • Palma G.
        • et al.
        The stress hormone norepinephrine increases migration of prostate cancer cells in vitro and in vivo.
        Int J Oncol. 2015; 47: 527-534
        • Jianguo K.
        • Xichun W.
        • Mingkun Z.
        • Qiaoling C.
        • Wenjin L.
        Large doses of propranolol for the treatment of infantile cephalic and facial hemangiomas: a clinical report of 38 cases.
        J Clin Pediatr Dent. 2015; 39: 268-271
        • Wrobel L.J.
        • Le Gal F.A.
        Inhibition of human melanoma growth by a non-cardioselective beta-blocker.
        J Invest Dermatol. 2015; 135: 525-531
        • Sorski L.
        • Melamed R.
        • Matzner P.
        • et al.
        Reducing liver metastases of colon cancer in the context of extensive and minor surgeries through beta-adrenoceptors blockade and COX2 inhibition.
        Brain Behav Immun. 2016; 58: 91-98
        • Santoro F.
        • Brunetti N.D.
        • Tarantino N.
        • et al.
        Dynamic changes of QTc interval and prognostic significance in takotsubo (stress) cardiomyopathy.
        Clin Cardiol. 2017; 40: 1116-1122
        • Guerra F.
        • Rrapaj E.
        • Pongetti G.
        • et al.
        Differences and similarities of repolarization patterns during hospitalization for Takotsubo cardiomyopathy and acute coronary syndrome.
        Am J Cardiol. 2013; 112: 1720-1724
        • Giannakopoulos K.
        • El-Battrawy I.
        • Gietzen T.
        • Ansari U.
        • Borggrefe M.
        • Akin I.
        Gender-based comparison of takotsubo syndrome versus myocardial infarction.
        QJM. 2019; 112: 355-362
        • Giannakopoulos K.
        • El-Battrawy I.
        • Schramm K.
        • et al.
        Corrigendum: comparison and outcome analysis of patients with Takotsubo cardiomyopathy triggered by emotional stress or physical stress.
        Front Psychol. 2017; 8: 1114
        • Yerasi C.
        • Koifman E.
        • Weissman G.
        • et al.
        Impact of triggering event in outcomes of stress-induced (Takotsubo) cardiomyopathy.
        Eur Heart J Acute Cardiovasc Care. 2017; 6: 280-286