title: Prevalence, associated factors and management implications of left ventricular outflow tract obstruction in takotsubo cardiomyopathy: a two-year, two-center experience.
abstract: BACKGROUND
  Some patients with Takotsubo cardiomyopathy (TTC) develop cardiogenic shock due to left ventricular outflow tract (LVOT) obstruction - there is, however, a paucity of data regarding this condition.
  
  
  METHODS
  Prevalence, associated factors and management implications of LVOT obstruction in TTC was explored, based on two-year data from two Belgian heart centres.
  
  
  RESULTS
  A total of 32 patients with TTC were identified out of 3,272 patients presenting with troponin-positive acute coronary syndrome. In six patients diagnosed with TTC (19%), a significant LVOT obstruction was detected by transthoracic echocardiography. Patients with LVOT obstruction were older and had more often septal bulging, and presented more frequently in cardiogenic shock as compared to those without LVOT obstruction (P < 0.05). Moreover, all patients with LVOT obstruction showed systolic anterior motion (SAM) of the anterior mitral valve leaflet, which was associated with a higher grade of mitral regurgitation (2.2±0.7 vs. 1.0±0.6, P<0.001). Adequate therapeutic management including fluid resuscitation, cessation of inotropic therapy, intravenous β-blocker, and the use of intra-aortic balloon pump resulted in non-inferior survival in TTC patients with LVOT obstruction as compared to those without LVOT obstruction.
  
  
  CONCLUSIONS
  TTC is complicated by LVOT obstruction in approximately 20% of cases. Older age, septal bulging, SAM-induced mitral regurgitation and hemodynamic instability are associated with this condition. Timely and accurate diagnosis of LVOT obstruction by echocardiography is key to successful management of these TTC patients with LVOT obstruction and results in a non-inferior outcome as compared to those patients without LVOT obstruction.
authors.affiliation: Department of Cardiology, Ghent University Hospital, De Pintelaan 185, B-9000 Ghent, Belgium. ole.debacker@gmail.com.
authors.forename: Ole
authors.initials: O
authors.lastname: De Backer
authors.forename: Philippe
authors.initials: P
authors.lastname: Debonnaire
authors.forename: Sofie
authors.initials: S
authors.lastname: Gevaert
authors.forename: Luc
authors.initials: L
authors.lastname: Missault
authors.forename: Peter
authors.initials: P
authors.lastname: Gheeraert
authors.forename: Luc
authors.initials: L
authors.lastname: Muyldermans
mesh_terms: D000319:Adrenergic beta-Antagonists / Q000627:therapeutic use; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001530:Belgium / Q000453:epidemiology; D002316:Cardiotonic Agents / Q000627:therapeutic use; D015150:Echocardiography, Doppler; D005260:Female; D005440:Fluid Therapy; D006439:Hemodynamics; D006801:Humans; D007423:Intra-Aortic Balloon Pumping; D008297:Male; D008875:Middle Aged; D008944:Mitral Valve Insufficiency / Q000453:epidemiology; D015995:Prevalence; D020127:Recovery of Function; D012189:Retrospective Studies; D012307:Risk Factors; D012770:Shock, Cardiogenic / Q000453:epidemiology; D054549:Takotsubo Cardiomyopathy / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology; D013997:Time Factors; D016896:Treatment Outcome; D016277:Ventricular Function, Left; D014694:Ventricular Outflow Obstruction / Q000175:diagnosis / Q000453:epidemiology* / Q000401:mortality / Q000503:physiopathology / Q000628:therapy*
chemical_list: D000319:Adrenergic beta-Antagonists; D002316:Cardiotonic Agents