Apical ballooning syndrome--a review of five cases.

INTRODUCTION: Takotsubo syndrome (apical ballooning syndrome) was described for the first time in Japan, at the beginning of the 1990s. It is characterized by the acute onset of extensive but transient akinesia of the apical and mid portions of the left ventricle, in the absence of significant coronary disease. OBJECTIVE: We describe five patients who were admitted to our hospital with this new syndrome between June 2004 and December 2005. These patients represented 0.8% of a total of 613 patients admitted for acute myocardial infarction in that period. RESULTS: All the patients were female, with a mean age of 60.2+/-10.3 years. Chest pain was the most frequent clinical presentation (n=5). A possible triggering factor, intense emotional stress, was identified in two patients. At admission, the electrocardiogram showed ST elevation in two patients and Q waves in the precordial leads in one. All cases had negative T waves in the precordial leads at some point. All patients had increased troponin levels but only two had elevated cardiac enzymes. The echocardiogram revealed extensive akinesia of the apical and mid portions of the left ventricle, and a thrombus was observed in one patient. Coronary angiography showed no significant lesions. Currently, all five patients are virtually asymptomatic, with regression of left ventricular wall-motion abnormalities on echocardiography. CONCLUSION: This is the first series of apical ballooning syndrome described in Portugal. Although rare, it should be considered in the differential diagnosis of acute myocardial infarction. Despite its transient nature, in the acute phase it can be a serious condition. More research is needed to better characterize this new entity.

Are degenerative changes in the aortic valve an additional important marker of atherosclerosis?

BACKGROUND AND AIM: Degenerative changes of the mitral annulus are associated with atherosclerotic disease. It has recently been suggested that degenerative changes in the aortic valve may also be associated with atherosclerosis. The intima-media thickness of the carotid arteries has been used as one of the best and earliest markers of atherosclerosis. The aim of this study was to evaluate whether the additional presence of degenerative changes in the aortic valve in coronary patients with mitral annular degenerative disease reflects different degrees of intima-media thickness as assessed by carotid ultrasonography. METHODS: The study group included 55 patients admitted for myocardial infarction who presented with degenerative changes of the mitral annulus assessed by echocardiography. Exclusion criteria were moderate or severe valvular heart disease and chronic renal failure. All patients underwent echocardiography, cardiac Doppler and carotid ultrasonography. Based on the echocardiographic findings, two sub-groups were formed: 1--with degenerative changes of the aortic valve; and 2--without degenerative changes of the aortic valve. Carotid ultrasonography was performed with a 7.5-10 MHz linear transducer and the following parameters were evaluated: 1--bilateral measurement of intima-media thickness in the common carotid artery; 2-- incidence of atheromatous plaques in the carotid arteries, and 3--incidence of >50% lesion in the internal carotid arteries assessed by pulsed Doppler (Vmax >125 cm/s). RESULTS: Thirty-three patients (aged 71.6 +/- 7.1 years), 21 men and 12 women, did not present degenerative changes in the aortic valve. The other group consisted of 22 individuals (aged 72.9 +/- 6.8 years), 14 men and 8 women, who did have such changes. Differences in age and gender distribution between the two groups were not significant. Patients with degenerative aortic valve disease had greater intima-media thickness than the control group (1.6 +/- 0.3 mm versus 1.3 +/- 0.4 mm, p < 0.001). Fifteen (68%) patients with aortic degenerative disease had plaques in the carotid arteries compared to 11 (33%) patients in the control group (p < 0.05). No significant differences were found between the two groups regarding the incidence of >50% atherosclerotic lesion in the internal carotid artery (22% versus 12%; NS). CONCLUSIONS: Patients with degenerative changes in the aortic valve presented significantly greater intima-media thickness and a higher incidence of atherosclerotic plaques than the control group, suggesting that their presence may constitute an additional important marker of severity of atherosclerotic disease.