Europace Advance Access originally published online on October 9, 2008
Europace 2008 10(12):1361-1362; doi:10.1093/europace/eun276
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EDITORIALS
Danger to the ventricular myocardium from prolonged ablation procedures combined with a long-lasting catecholamine infusion for provocative arrhythmia testing
Department of Cardiology, Fundación Jiménez Díaz-Capio, Universidad Autónoma de Madrid, Av Reyes Católicos 2, 28040 Madrid, Spain
Manuscript submitted 15 September 2008. Accepted after revision 16 September 2008.
* Corresponding author. Tel: +34 91 544 1636; fax: +34 91 549 9402. E-mail address: jfarre{at}fjd.es
In this issue of Europace, Hasdemir et al. report on a case of what they term ‘stress cardiomyopathy (tako-tsubo)’ following radiofrequency ablation in the right ventricular outflow tract.1
The most relevant lesson from this case report is that very prolonged ablation procedures may result in a transient left ventricular (LV) systolic dysfunction or stress cardiomyopathy, particularly when catecholamines are infused over a long period to test the result of intervention. In this case, radiofrequency was delivered for up to 21 min, which meant that the procedure was very long-lasting and most likely stressful for a non-sedated patient. This, together with the also very prolonged duration of the dopamine infusion (maintained during the whole ablation procedure plus for 90 min after the last radiofrequency application) implies a strong and protracted intrinsic and extrinsic adrenergic stimulus, the known common denominator for developing a stress cardiomyopathy.2
A second issue raised by this case report is the appropriateness of using the term tako-tsubo for a transient almost global, not apical or mid-ventricular, hypokinesia–akinesia–dyskinesia. The term tako-tsubo should probably be reserved for those forms of transient apical, or apical and mid-ventricular, LV akinesia–dyskinesia in which the coronary arteries are normal and a systolic apical ballooning mimics a Japanese fishing gear called tako-tsubo due to the distal akinesia but also to the basal hyper-contractility. More global forms of transient LV systolic dysfunctions in which an acute myocarditis is excluded with gadolinium-enhanced magnetic resonance imaging should not be called tako-tsubo syndrome.2 In spite of certain similarities between both phenotypes of transient LV systolic dysfunction, the aetio-pathogenesis of tako-tsubo may be different. The cause of tako-tsubo remains controversial. Several potential mechanisms have been proposed, such as acute myocarditis, toxic effect of catecholamines on the myocardium, multiple vessel coronary artery spasm, micro-vascular ischaemia, transient dynamic severe obstruction at the LV outflow tract or mid-ventricular level, and transient occlusion of a long left anterior descending (LAD) coronary artery with a well-developed recurrent segment supplying blood to the LV infero-apical segment.
We demonstrated the presence of a disrupted unstable atherosclerotic plaque in a prospective study examining with intravascular ultrasound the LAD artery early after the onset of symptoms in patients with tako-tsubo LV morphology and angiographically normal coronary arteries.3 We postulated that tako-tsubo transient apical ballooning was an acute coronary syndrome with initial athero-thrombotic occlusion of the LAD followed by early reperfusion, minimal enzymatic release, and LV stunning rather than necrosis. Although it has been claimed that this mechanism does not entirely explain the extent of regional wall motion abnormality, we had previously shown that in tako-tsubo paitents the LAD constantly had a long distal wrapping segment that could account for the wide apical ballooning observed in these cases.4 More global forms of transient LV systolic dysfunction, such as that developed by the patient discussed in this case report, are less well known than the true tako-tsubo variety and should be termed ‘stress cardiomyopathy’.2
In this case, 4 years before ablation, the patient had an episode of decompensated heart failure with transient LV systolic dysfunction from which she spontaneously recovered since the LV ejection fraction was estimated to be 51% before ablation. Thus, this patient had two episodes of transient LV systolic dysfunction. Recurrences can occur in cases of typical tako-tsubo stress cardiomyopathy and possibly this can also be observed in instances of more global temporary LV systolic dysfunction.5 It would have had interest to know the pattern of LV dysfunction in the first episode.
The ECG of the patient reported by Hasdemir et al. shows pathological Q waves in III, AVF, and from V1 to V3. It is not mentioned by the authors when these Q-waves appeared, or how transient or permanent they were. Information regarding the global form of stress cardiomyopathy is very scanty. In the better described tako-tsubo variant, pathological Q-waves have been described in 6–31% of patients, sometimes of transient nature and on other occasions persistent.6
Stress cardiomyopathy and tako-tsubo are not frequently acknowledged dangers from ablation procedures. Appropriate sedation, a limited duration of intervention, and a limitation of catecholamine infusion might prevent this complication. We appreciate the difficulties of defining when to stop, how much dopamine is excessive, and which type of sedation would be best not to interfere with the ablation procedure, but if we become aware of these complications a reasonable solution could be found.
Footnotes
The opinions expressed in this article are not necessarily those of the Editors of Europace or of the European Society of Cardiology.
References
[1] Hasdemir C, Yavuzgil O, Simsek E, Ulucan C, Cinar CS. Stress cardiomyopathy (tako-tsubo) following radiofrequency ablation in the right ventricular outflow tract. Europace (2008) 10:1452–4.
[2] Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation (2008) 118:397–409.
[3] Ibanez B, Navarro F, Cordoba M, M-Alberca P, Farre J. Tako-tsubo transient left ventricular apical ballooning: is intravascular ultrasound the key to resolve the enigma? Heart (2005) 91:102–4.
[4] Ibáñez B, Navarro F, Farré J, Marcos-Alberca P, Orejas M, Rábago R, Rey M, Romero J, Iñiguez A, Córdoba M. Tako-tsubo syndrome associated with a long course of the left anterior descending coronary artery along the apical diaphragmatic surface of the left ventricle. Rev Esp Cardiol (2004) 57:209–16.[CrossRef][Web of Science][Medline]
[5] Elesber A, Prasad A, Lennon R, Lerman A, Rihal CS. Four-year recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol (2007) 50:448–52.
[6] Bybee KA, Kara T, Prasad A, Lerman A, Barsness G, Wright RS, Rihal C. Transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med (2004) 141:858–65.
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Related articles in Europace:
- Stress cardiomyopathy (Tako-Tsubo) following radiofrequency ablation in the right ventricular outflow tract
- Can Hasdemir, Oguz Yavuzgil, Evrim Simsek, Cem Ulucan, and Cahide S. Cinar
Europace 2008 10: 1452-1454.[Abstract] [Full Text]
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