Case Report

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American Journal of Emergency Medicine

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American Journal of Emergency Medicine 32 (2014) 108.e1-108.e3

Transient left ventricular and stomach apical ballooning syndromes: when the trigger is also a clinical emergency

Abstract

A 59-year-old woman was referred to our emergency department because of Epigastric pain and incoercible vomit. Electrocardiogram showed ST-segment elevation in anterior-lateral leads, but coronary angiogram revealed normal coronary tree and left ventricular angiography showed apical and midventricular akinesis with pre- served basal systolic function: a diagnosis of apical ballooning syndrome was made. During the following days, the patient complained about persistent abdominal pain, and a nasogastric tube drained more than 1000 cc of dark fecaloid material. Urgent Abdominal computed tomography scan showed a mural thrombus in the apex of the left ventricle and a huge diaphragmatic hernia through which more than one-half of the stomach was herniated and presented a sort of “apical stomach ballooning.” Gastropexy was done; surgical diagnosis was a type IV giant diaphragmatic hernia complicated by recent gastric volvulus caused by rotation along the longitudinal cardiopyloric axis. Type IV giant diaphragmatic hernia is relatively rare, representing only about 5% to 7% of all hernias. Gastric volvulus is a severe complication, with acute mortality reported to be as high as 30% to 50%. In our case, a severe life-threatening condition as gastric volvulus triggered an apical ballooning syndrome, a transient cardiomyopathy, usually induced by emotional stressors with a long-term good prognosis. Apical ballooning syndrome must be considered an epiphenomenon of other organic diseases that may have an important role in the prognosis of the patient not only in acute but also in chronic setting. Only early determination of the true cause of apical ballooning syndrome ensures a proper treatment.

Left ventricular apical ballooning syndrome (Tako-Tsubo) is an acute stress-induced cardiomyopathy characterized by transient left ventricular dysfunction [1]. Although Tako-Tsubo mimics an acute coronary syndrome, generally there is no evidence of obstructive coronary artery disease. Tako-Tsubo is estimated to represent 1% to 2

% of hospital admissions for ST-segment elevation myocardial infarction [2,3]. The prognosis is good, if complications of the acute phase are promptly recognized and treated [4,5].

A 59-year-old woman was referred to our emergency department because of epigastric pain and incoercible vomit. She was hypertensive in medical therapy with associated Paraneoplastic syndrome caused by Renal cell carcinoma and previous left nephrectomy; in January 2013, she started medical therapy with pazopanib. At admission, she seemed restless and diaphoretic with unremarkable physical examination. Blood pressure was 130/80 mm Hg, pulse rate was 82 beats/min, and oxygen saturation was 98%. The abdomen was treatable but widely tender. Her chest x-ray showed an elevation of left dome of diaphragm.

A nasogastric tube was successfully positioned with a drainage of 200 cc of gastric content with clinical benefit. Routinely, electrocardiogram showed ST-segment elevation in anterior-lateral leads. ST-segment elevation myocardial infarction was hypothesized. urgent coronary angiography was performed, and there was no evidence of obstructive coronary artery disease. Left ventricular angiography revealed the typical apical ballooning with preserved basal systolic function (Fig. 1). Ultrasensitive troponin I peak was 16.00 ug/L. Transthoracic echocar- diography confirmed wall motion abnormalities and severe systolic left ventricle dysfunction (ejection fraction, 25%), identified alterated Diastolic function (increased E/e? ratio), and excluded dynamic left ventricle outflow tract obstruction and right ventricular involvement. During the following observation, seriated transthoracic echocardiog- raphy controls and electrocardiograms showed a gradual recovery of left ventricular contractility and resolution of ST-segment elevation, but the patient complained about persistent abdominal pain and nausea. Hemodynamic parameters were stable, and no increased troponin I was detected. During the visit, there were no signs of peritonitis, but the nasogastric tube drained more than 1000 cc of dark fecaloid material. Urgent abdominal computed tomography scan was performed and showed type IV giant diaphragmatic hernia with a hole in the left dome of diaphragm posteriorly through which more than one-half of the stomach was herniated and presented a sort of “apical stomach ballooning” (Fig. 2). Computed tomography scan also revealed a mural oval-shaped thrombus in the apex of the left ventricle. Despite the potential thromboembolic complications and the inComplete recovery of global systolic function, considered the emergency setting because of diaphragmatic hernia [6-8], through minimally invasive laparoscopic techniques, the hole was repaired with reduction of the stomach and gastropexy was done with clinical improvement. The herniated part of the stomach was congested and with thickened wall as a recent organ-axial volvulus caused by rotation along the longitudinal cardiopyloric axis. Although heparin was continued, probably because of improvement in left ventricular function and recovery of apical wall motion abnormalities, the apical thrombus assumed a floating mor- phology protruding in the left ventricle (Fig. 3, video clips 1-2), warfarin was added in the treatment. We performed as recommended a cardiac magnetic resonance [9], which confirmed the Full recovery of the left ventricular contractility and excluded any thrombus in the left or right ventricle. The examination also showed soft edema/inflammation at the apical segments of the anterior wall of the left ventricle, of the septum, and of the apex because of the recent consequence of Tako-Tsubo (Fig. 4, video clip 3).

This is an unusual case of apical ballooning syndrome complicated

by left ventricular thrombosis associated to a physical stressful event: an apical stomach ballooning caused by a giant diaphragmatic hernia

0735-6757/$ - see front matter (C) 2013

108.e2 C. Zawaideh et al. / American Journal of Emergency Medicine 32 (2014) 108.e1-108.e3

Fig. 1. Left ventriculography: diastolic frame (A) and systolic frame (B). Note the morphology of left ventricular apical ballooning, akinesis confined to the apex and mild segments of the ventricle, despite preserved contractility of the basal segments. The left ventricle in systole resembles the shape of a Japanese pot (Tako-Tsubo) with a narrow neck and wide base. The Wall motion abnormality was typically extending beyond the distribution of any single coronary artery.

Fig. 2. Contrast-enhanced axial computed tomography scan. A, Soft tissue window shows the giant diaphragmatic hernia type IV through the interruption in the back portion of the left diaphragm; the stomach was herniated and presented a sort of apical stomach ballooning. We can see the diluted water-soluble contrast agent (black arrow) in the body of the stomach administered per os and the air in the body of the stomach (white arrow). B, Lung window shows the atelectasis lung tissue (curved arrow), the presence of herniation of the fundus (black arrow), and the body of the stomach (asterisk) above the diaphragm.

and Acute gastric volvulus, whose mortality has been reported to be as high as 30% to 50% [10]. This potentially life-threatening condition required surgical intervention [11-13] despite the risk of thrombo- embolic complication and acute heart failure during the early phases of Tako-Tsubo. It is known that apical ballooning syndrome with

apical aneurysm [14-16], acute left ventricle dysfunction, severe impairment in left ventricle ejection fraction, and increased sympa- thetic activation should promote thrombus apposition in the left ventricle cavity. In addition, our patient presented a prothrombotic state caused by paraneoplastic syndrome (advanced renal cell

Fig. 3. Two-dimensional transthoracic echocardiography, zoom-in modified Apical 4-chamber view. A, Mural oval-shaped thrombus, (white arrow), flat and parallel to the endocardial surface, in the apex of the left ventricle. B, The apical thrombus (white arrow), with a floating morphology protruding in the left ventricle. It was considered mobile because some portion moved independent of the underlying myocardium. The improvement in left ventricle function and recovery of apical wall motion abnormalities induced the complete detachment of the thrombus from the apical wall, transforming a mural thrombus in a protruding, floating one. The dynamic, fast recovery in apical wall motion abnormalities promoted thrombus detachment with potential embolic complications.

C. Zawaideh et al. / American Journal of Emergency Medicine 32 (2014) 108.e1-108.e3 108.e3

Fig. 4. Cardiovascular magnetic resonance: the examination was acquired with a 1.5-T machine and dedicated multielement phased-array coil, with cardiac-respiratory trigger/ gating and Turbo Spin Echo-T2 Weighted sequences, without and with fat suppression and functional estimate through Steady-State Free Precession multiphase sequences. The examination was completed with the administration of gadolinium via e.v. The Short T1 Inversion Recovery 2-chamber (A), 3-chamber (B), and short-axis (C) sequences show soft edema/inflammation (white arrow) of the left ventricle at the apical segments of the anterior wall, of the septum, and of the apex because of the recent consequence of transient left ventricular apical ballooning syndrome. The Cardiovascular Magnetic Resonance excludes also the presence of any thrombus in the left or right ventricle.

carcinoma [17,18] and cancer therapy). Pazopanib is an orally administered tyrosine kinase inhibitor. It is known that the incidences of arterial thrombotic events are higher in patients treated with pazopanib compared with placebo [19,20]. Therefore, pazopanib probably contributed in our case to the development of left ventricular thrombosis in the setting of Tako-Tsubo. We demonstrated how clinicians must be aware not only on left ventricle apical ballooning syndrome management and treatment but also on the underlying clinical conditions that play an important role in determining prognosis, evolution, and survival in such a complicated patient.

Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ajem.2013.08.016.

Camilla Zawaideh MD Milena Aste MD Cardiology Unit

IRCCS Azienda Ospedaliera Universitaria San Martino

IST, Genova, Italy

Ombretta Cutuli MD

Emergency Medicine Unit IRCCS Azienda Ospedaliera Universitaria San Martino

IST, Genova, Italy

Irilda Budaj MD

Radiology Unit IRCCS Azienda Ospedaliera Universitaria San Martino

IST, Genova, Italy

Gian Paolo Bezante MD Claudio Brunelli MD Manrico Balbi MD Alberto Valbusa MD Cardiology Unit

IRCCS Azienda Ospedaliera Universitaria San Martino

IST, Genova, Italy E-mail address: [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.08.016

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