Author + information
- Ahmad A. Elesber, MD,
- Abhiram Prasad, MD, FACC,
- Kevin A. Bybee, MD,
- Uma Valeti, MD,
- Arashk Motiei, MD,
- Amir Lerman, MD, FACC,
- Krishnaswamy Chandrasekaran, MD, FACC and
- Charanjit S. Rihal, MD, FACC⁎ ()
- ↵⁎Mayo Clinic College of Medicine, Division of Cardiovascular Diseases, 200 First Street SW, Rochester, Minnesota 55905
To the Editor:Reports on “the transient left ventricular apical ballooning syndrome” (TLVABS) have described the peculiar, yet characteristic transient regional systolic dysfunction involving the left ventricle (LV) (1). None of these studies have reported right ventricular (RV) involvement. The goal of this study was to determine the prevalence and clinical impact of associated RV dysfunction in patients with TLVABS.
From January 2002 to June 2005, 30 consecutive patients met the proposed Mayo criteria for the clinical diagnosis of TLVABS (1) and were enrolled in the study. All patients gave permission for the use of medical records for research purposes.
Transthoracic echocardiography was performed in the acute setting in 25 of the 30 patients using standard echocardiographic windows. Right ventricular systolic function was assessed visually from all available echocardiographic windows. Five patients underwent cardiac magnetic resonance imaging within one week of presentation.
Continuous variables were compared using a two-tailed Student ttest. Differences between categorical variables were analyzed by using chi-square tests. A logistic regression analysis was performed to differentiate the effect of LV ejection fraction from RV involvement, with a p value <0.05 considered significant.
All 30 patients were women (mean age, 71 years; range, 43 to 88 years) with angiographically normal coronary arteries or nonobstructive stenoses (<50% luminal diameter stenosis).
Right ventricular function could be adequately evaluated using standard apical and subcostal views in all 25 patients. Significant RV dysfunction was found in 8 (group 2) of the 25 patients. In patients with RV involvement, there was uniform involvement of the RV apex (dyskinesis, akinesis, or severe hypokinesis) and sparing of the RV base. The midventricle was hypokinetic in six patients of the total eight with RV involvement. Seven patients from group 2 had echocardiography at follow-up. These seven patients had subsequently improvement of their LV ejection fraction (29 ± 10% vs. 58 ± 9%, p < 0.001) and of their RV function as assessed visually. The inferior vena cava diameter (1.9 ± 0.5 cm vs. 1.7 ± 0.5 cm, p = 0.83) did not change significantly at follow-up, but the tricuspid regurgitation velocity did (3.2 ± 0.5 cm/s vs. 2.6 ± 0.4 cm/s, p = 0.037).
Seventeen patients (group 1) had normal RV function at the time of initial presentation. Fifteen of these 17 had repeat echocardiography. Their LV ejection fraction improved significantly (43 ± 14% vs. 63 ± 9%, p < 0.001), but there was no change in RV function, inferior vena cava diameter, or in tricuspid valve regurgitation velocity (p > 0.05).
In the five patients that underwent cardiac magnetic resonance imaging, four had severe impairment of RV systolic function involving the distal (apical) segments, with two patients exhibiting severe hypokinesis of the mid-RV segments. Only one of the five patients had normal RV function. None of the five had delayed gadolinium enhancement, which is consistent with viable myocardium and the absence of infarction.
To evaluate the clinical and hemodynamic impact of RV involvement, we compared group 1 to group 2. There was no statistical difference between the two groups with regard to age, coronary artery risk factors, discharge cardiac medications, presentation heart rate or blood pressure, electrocardiogram characteristics, cardiac catheterization findings, and maximal troponin release (data not shown).
The echocardiographic findings and complications incurred by both groups are summarized in Table 1.The presentation LV ejection fraction was significantly reduced in group 2 as compared with group 1 but not at follow-up. The presentation tricuspid regurgitation velocity was significantly higher in group 2 as compared with group 1 but not at follow-up.
Patients in group 2 required a hospitalization on average four days longer than patients in group 1. Complication rate also was significantly higher in group 2 patients as compared with group 1.
In a logistic regression analysis that included both LV ejection fraction and RV involvement, only RV involvement was associated with severe congestive heart failure (i.e., New York Heart Association functional class III or IV; p = 0.014) and the combined occurrence of severe congestive heart failure or requirement for intra-aortic balloon pump or cardiopulmonary resuscitation (p = 0.0081).
The main and novel findings of this report are: 1) RV involvement in TLVABS is common, transient, and, when present, portends a longer and more critical hospitalization course as compared with patients with isolated LV involvement; and 2) RV involvement, when present, follows a similar pattern of regional wall motion abnormalities as does LV involvement in this syndrome.
It is now clear that RV function is one of the most useful indicators for patient survival in ischemic heart failure (2) and in patients with congenital heart disease (3). In our study, we show for the first time that RV involvement was common in patients with TLVABS, with approximately one-third of patients presenting with detectable RV dysfunction on echocardiography. Even if we assume that all other five patients who did not have echocardiography at initial evaluation had normal RV function, at least one-quarter (8 of 30) of patients with TLVABS have RV involvement. The RV involvement was transient but had a significant impact on hospitalization length and hemodynamic instability. This effect was independent from the accompanying LV dysfunction. Clinicians should be aware of the possibility of RV dysfunction because it might have a significant impact on patient morbidity, management, and, ultimately, outcome.
The major limitation of the study lies in its retrospective nature and relatively small number of patients. The echocardiograms were obtained for clinical use and specific imaging was not performed for the assessment of RV function. In addition, although echocardiography is used to assess RV function, technical limitations to imaging exist because of the complexity of the RV anatomy (4).
In conclusion, in TLVABS, RV involvement is relatively common and is reversible. Right ventricular involvement has a negative impact on hospital stay and morbidity, and its identification can help predict hemodynamic instability. Given our findings, we propose relabeling this syndrome as “transient cardiac apical ballooning syndrome.”
- American College of Cardiology Foundation
- Polak J.F.,
- Holman B.L.,
- Wynne J.,
- Colucci W.S.
- Oldershaw P.