Hemodynamic Assessment in Takotsubo Syndrome

• Published in: Journal of the American College of Cardiology Vol. 81; no. 20; pp. 1979 - 1991
• Main Authors: Stiermaier, Thomas, Reil, Jan-Christian, Sequeira, Vasco, Rawish, Elias, Mezger, Matthias, Pätz, Toni, Paitazoglou, Christina, Schmidt, Tobias, Frerker, Christian, Steendijk, Paul, Reil, Gert-Hinrich, Eitel, Ingo
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 23.05.2023
• Subjects: Cardiovascular; Hemodynamics; Humans; Myocardial Contraction - physiology; pathophysiology; Stroke Volume - physiology; Takotsubo Cardiomyopathy - diagnosis; Takotsubo syndrome; Ventricular Function, Left - physiology; CaMK II; cMyBP-C; Takotsubo syndrome; PV; LVESV150; LV; dP/dtmin; LVESP; EDP; TTS; EDV; pathophysiology; LVEDV; V0; ß; EDPVR; dP/dtmax; ESP; CMR; ESV; k; ESPVR; hemodynamics; Ees; LVEDV15; Ea; ATP; cardiac myosin-binding protein-C; pressure–volume; left ventricular end-diastolic volume; end-diastolic pressure; left ventricular; minimal rate of change in pressure over time; dP/dt max; end-diastolic pressure-volume relationship; left ventricular end-diastolic volume at a pressure of 15 mm Hg; dP/dt min; end-systolic elastance; end-systolic pressure–volume relationship; left ventricular end-systolic volume at a pressure of 150 mm Hg; E a; Ca 2+/calmodulin-dependent protein kinase II; effective arterial elastance; end-diastolic volume; volume–axis intercept of the end-systolic pressure-volume relationship; maximal rate of change in systolic pressure over time; V 0; end-systolic volume; end-systolic pressure; stiffness coefficient; E es; adenosine triphosphate; fitting constant; left ventricular end-systolic pressure; cardiac magnetic resonance
• ISSN: 0735-1097; 1558-3597; 1558-3597
• DOI: 10.1016/j.jacc.2023.03.398

Takotsubo syndrome (TTS) is a reversible form of heart failure with incompletely understood pathophysiology. This study analyzed altered cardiac hemodynamics during TTS to elucidate underlying disease mechanisms. Left ventricular (LV) pressure–volume loops were recorded in 24 consecutive patients with TTS and a control population of 20 participants without cardiovascular diseases. TTS was associated with impaired LV contractility (end-systolic elastance 1.74 mm Hg/mL vs 2.35 mm Hg/mL [P = 0.024]; maximal rate of change in systolic pressure over time 1,533 mm Hg/s vs 1,763 mm Hg/s [P = 0.031]; end-systolic volume at a pressure of 150 mm Hg, 77.3 mL vs 46.4 mL [P = 0.002]); and a shortened systolic period (286 ms vs 343 ms [P < 0.001]). In response, the pressure–volume diagram was shifted rightward with significantly increased LV end-diastolic (P = 0.031) and end-systolic (P < 0.001) volumes, which preserved LV stroke volume (P = 0.370) despite a lower LV ejection fraction (P < 0.001). Diastolic function was characterized by prolonged active relaxation (relaxation constant 69.5 ms vs 45.9 ms [P < 0.001]; minimal rate of change in diastolic pressure –1,457 mm Hg/s vs –2,192 mm Hg/s [P < 0.001]), whereas diastolic stiffness (1/compliance) was not affected during TTS (end-diastolic volume at a pressure of 15 mm Hg, 96.7 mL vs 109.0 mL [P = 0.942]). Mechanical efficiency was significantly reduced in TTS (P < 0.001) considering reduced stroke work (P = 0.001), increased potential energy (P = 0.036), and a similar total pressure–volume area compared with that of control subjects (P = 0.357). TTS is characterized by reduced cardiac contractility, a shortened systolic period, inefficient energetics, and prolonged active relaxation but unaltered diastolic passive stiffness. These findings may suggest decreased phosphorylation of myofilament proteins, which represents a potential therapeutic target in TTS. (Optimized Characterization of Takotsubo Syndrome by Obtaining Pressure Volume Loops [OCTOPUS]; NCT03726528) [Display omitted]