Objectives This study assessed the incidence of long-term adverse outcomes in patients with Takotsubo syndrome (TTS). Background The long-term prognosis of TTS is controversial. It is also unclear whether presenting characteristics are associated with the subsequent long-term prognosis. Methods We searched the PubMed, Embase, and Cochrane databases and reviewed cited references up to March 31, 2018, to identify studies with >6 months of follow-up data. Results Overall, we selected 54 studies that included a total of 4,679 patients (4,077 women and 602 men). Death during admission occurred in 112 patients (2.4%), yielding a frequency of 1.8% (95% confidence interval [CI]: 1.2% to 2.5%), with significant heterogeneity (I2 = 78%; p  Conclusions Our update analysis of patients discharged alive after TTS showed that long-term rates of overall mortality and recurrence were not trivial, and that some presenting features (older age, physical stressor, and atypical ballooning) were significantly associated with an unfavorable long-term prognosis.

Long-Term Prognosis and Outcome Predictors in Takotsubo Syndrome: A Systematic Review and Meta-Regression Study

Multisite pacing for the treatment of heart failure has added a new dimension to the electrocardiographic evaluation of device function. During left ventricular (LV) pacing from the appropriate site in the coronary venous system, a correctly positioned lead V1 registers a right bundle branch block pattern with few exceptions. During biventricular stimulation associated with right ventricular (RV) apical pacing, the QRS is often positive in lead V1. The frontal plane QRS axis is usually in the right superior quadrant and occasionally in the left superior quadrant. Barring incorrect placement of lead V1 (too high on the chest), lack of LV capture, LV lead displacement or marked latency (exit block or delay from the stimulation site), ventricular fusion with the spontaneous QRS complex, a negative QRS complex in lead V1 during biventricular pacing involving the RV apex probably reflects different activation of an heterogeneous biventricular substrate (ischemia, scar, His-Purkinje participation in view of the varying patterns of LV activation in spontaneous left bundle branch block) and does not necessarily indicate a poor (electrical or mechanical) contribution from LV stimulation. In this situation, it is imperative to rule out the presence of coronary venous pacing via the middle cardiac vein or even unintended placement of two leads in the RV. During biventricular pacing with the RV lead in the outflow tract, the paced QRS in lead V1 is often negative and the frontal plane paced QRS axis is often directed to the right inferior quadrant (right axis deviation). In patients with sinus rhythm and a relatively short PR interval, ventricular fusion with competing native conduction during biventricular pacing may cause misinterpretation of the ECG because narrowing of the paced QRS complex simulates appropriate biventricular capture. This represents a common pitfall in device follow-up. Elimination of ventricular fusion by shortening the AV delay, is often associated with clinical improvement. Anodal stimulation may complicate threshold testing and should not be misinterpreted as pacemaker malfunction. One must be cognizant of the various disturbances that can disrupt 1:1 atrial tracking and cause loss of ventricular resynchronization. (1) Upper rate response. The upper rate response of biventricular pacemakers differs from the traditional Wenckebach upper rate response of conventional antibradycardia pacemakers because heart failure patients generally do not have sinus bradycardia or AV junctional conduction delay. The programmed upper rate should be sufficiently fast to avoid loss of resynchronization in situations associated with sinus tachycardia. (2) Below the programmed upper rate. This may be caused by a variety of events (especially ventricular premature complexes and favored by the presence of first-degree AV block) that alter the timing of sensed and paced events. In such cases, atrial events become trapped into the postventricular atrial refractory period at atrial rates below the programmed upper rate in the presence of spontaneous AV conduction. Algorithms are available to restore resynchronization by automatic temporary abbreviation of the postventricular atrial refractory period.

Electrocardiographic follow-up of biventricular pacemakers.

Takotsubo cardiomyopathy (TCMP), also known as stress cardiomyopathy or broken‐heart syndrome, is an increasingly recognized form of transient left ventricular (LV) dysfunction that is often completely reversible.1, 2, 3, 4 It is diagnosed in ≈1% to 2% of patients initially presenting with symptoms suggestive of acute coronary syndrome.2 It often presents with dyspnea, hypotension, syncope, elevated troponin levels, and ST elevations or T wave inversions on electrocardiography.1 Coronary angiography classically reveals normal coronary arteries with no significant stenosis, though bystander coronary disease could be present, which is often mild and not severe enough to account for the degree of ventricular dysfunction.1, 2 Complications can occur early in its course and include arrhythmia, thrombus formation, LV outlet tract obstruction, ventricular rupture, cardiogenic shock, and cardiac arrest.1, 3 An up to 8% mortality rate has been reported with excellent recovery in 95%.3 Classically it has been described following a physical and emotional event, with recurrence rates of 10% to 11% on revival of triggering factors.1

Several variants of TCMP have been described. The typical or apical variant consists of a hyperkinetic LV base with focal apical akinesis resulting in apical ballooning and reduced ejection fraction. Other variants such as the inverted or basal pattern (circumferential basal hypokinesis and apical hypercontractility), the mid LV variant (circumferential midventricular hypokinesis and both basal and apical hypercontractility), and the biventricular apical and right ventricular pattern have been described.1, 4

The exact pathogenesis is not fully understood with vast unanswered questions remaining, though a central role of catecholamines has been widely accepted. The stress related to metabolic dysfunction can be the initial trigger for the sympathetic surge found in this disorder. Several case reports have described its occurrence secondary to a number of endocrine disorders, though this has not been comprehensively evaluated. Here we have attempted to review all of the published reports of associations of endocrine conditions with TCMP and discuss some postulated mechanisms by which this may occur. This review will mainly focus on the potential association of pituitary, thyroid, adrenal, and estrogen metabolic disorders with this transient reversible cardiomyopathy and how hormones can impact cardiac function. This review suggests that hormonal dysregulation should be considered in patients presenting with cardiac abnormalities.

Association of Endocrine Conditions With Takotsubo Cardiomyopathy: A Comprehensive Review.

Purpose of reviewCardiac resynchronization therapy, a biventricular pacemaker-based therapy for heart failure, is increasingly being used based on a variety of clinical studies. However, the complications and risks related to different aspects of this novel therapy are not well documented. This revi

Complications of biventricular pacing.

Takotsubo syndrome (TTS), also known as Takotsubo cardiomyopathy, is a transient left ventricular wall dysfunction that is often triggered by physical or emotional stressors. Although TTS is a rare disease with a prevalence of only 0.5% to 0.9% in the general population, it is often misdiagnosed as acute coronary syndrome. A diagnosis of TTS can be made using Mayo diagnostic criteria. The initial management of TTS includes dual antiplatelet therapy, anticoagulants, beta-blockers, angiotensin-converting enzyme inhibitors or aldosterone receptor blockers, and statins. Treatment is usually provided for up to three months and has a good safety profile. For TTS with complications such as cardiogenic shock, management depends on left ventricular outflow tract obstruction (LVOTO). In patients without LVOTO, inotropic agents can be used to maintain pressure, while inotropic agents are contraindicated in patients with LVOTO. In TTS with thromboembolism, heparin should be started, and patients should be bridged to warfarin for up to three months to prevent systemic emboli. Our comprehensive review discussed the management in detail, derived from the most recent literature from observational studies, systematic review, and meta-analyses.

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Management of Takotsubo Syndrome: A Comprehensive Review

Management of Takotsubo cardiomyopathy in non-academic hospitals in France: The Observational French SyndromEs of TakoTsubo (OFSETT) study.

The aim of the study was to evaluate, in recipients of biventricular pacing systems, the risk of asystole due to ventricular pacing inhibition by sensing the left atrial signals by the LV lead at conventional sensitivity. Long-term ventricular sensitivity was programmed at > or = 4 m V in 17 consecutive recipients of ventricular resynchronization systems implanted for chronic management of congestive heart failure. Ventricular pacing inhibition due to AV cross-talk on spontaneous left atrial electrogram (AVCSA) was tested at a 2 mV ventricular sensitivity immediately after implantation of the stimulation system and 1 month later. Pacemaker dependence was also tested during temporary VVI pacing at a rate of 30 beats/min. AVCSA was observed in three patients. It was present on the day of implantation in one patient, and developed within the first month in two others. Asystole was observed in two of the three cases of AVCSA. Three pacemaker nondependent patients at the time of system implantation had become pacemaker dependent at 1 month. AVCSA was observed only with LV leads positioned in the great cardiac vein. In conclusion, asystole due to AVCSA was observed in 11% of recipients of ventricular resynchronization stimulation systems. Care should be taken in these patients to minimize the risk of atrial sensing by the LV lead, preferably avoiding its placement in the great cardiac vein. This phenomenon could be eliminated by the programmability of a right ventricular only sensing configuration.

Bernard Jouve

Papers

Management of Takotsubo cardiomyopathy in non-academic hospitals in France: The Observational French SyndromEs of TakoTsubo (OFSETT) study.

Atrioventricular cross-talk in biventricular pacing: a potential cause of ventricular standstill.