Cardiomyopathy
Prognostic Usefulness of the Ballooning Pattern in Patients With Takotsubo Cardiomyopathy

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The aim of the present analysis was to evaluate the prognostic impact of different ballooning patterns in patients with Takotsubo cardiomyopathy (TTC). A total of 285 consecutive patients with TTC were included. Clinical characteristics and short- and long-term outcomes were compared between patients with typical apical ballooning (n = 204) and patients with an atypical ballooning pattern including midventricular and basal ballooning (n = 81). Patients with typical apical ballooning were significantly older (73.3 ± 10.2 vs 68.4 ± 10.3 years; p <0.01) and had a higher prevalence of diabetes mellitus (25.5% vs 12.3%; p = 0.02). The initial left ventricular (LV) ejection fraction was significantly lower in case of apical ballooning (41.5 ± 10.4% vs 46.9 ± 10.9%; p <0.01) but recovered to normal values in both groups (58.4 ± 8.0 vs 59.7 ± 7.0; p = 0.25). Although 28-day mortality did not differ significantly (p = 0.10), typical apical ballooning was associated with an increased 6-month (13.4% vs 1.3%; hazard ratio [HR] 10.81, 95% confidence interval [CI] 1.47 to 79.66; p = 0.02) and long-term mortality rates (28.9% vs 14.5%; HR 2.24, 95% CI 1.17 to 4.71; p = 0.02). A landmark analysis which included only patients who survived the first 6 months after the initial event demonstrated similar mortality rates in patients with typical (17.9%) and atypical (13.3%) ballooning (HR 1.36, 95% CI 0.67 to 2.79; p = 0.40). In conclusion, in patients with TTC, typical apical ballooning is associated with more severe LV dysfunction at acute presentation and higher mortality rates within the first 6 months after the initial event. After complete recovery of LV function, prognosis is similar in patients with typical and atypical ballooning patterns.

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Methods

Consecutive patients with TTC presenting to the University of Leipzig–Heart Center from January 2005 to December 2013 or the University Heart Center of Lübeck from February 2004 to April 2014 were prospectively identified and included in the trial. TTC was diagnosed based on the Mayo Clinic criteria.1 Coronary angiography was performed in all patients to exclude significant obstructive coronary artery disease (>50%) or evidence of acute plaque rupture. Furthermore, all patients underwent left

Results

TTC was diagnosed in 286 patients presenting to the 2 tertiary care centers during the study period. One patient demonstrated isolated right ventricular ballooning and was excluded from the study, resulting in 285 patients with TTC in the final analysis. Diagnosis confirmation through cardiovascular magnetic resonance was available in 125 patients (44%) and demonstrated focal myocardial edema in 89% and subtle fibrosis or necrosis (3 standard deviations above remote myocardium) in 9% of

Discussion

The present study compared short-term and long-term mortality rates in patients with TTC with typical and atypical ballooning patterns. The data show that typical apical ballooning is associated with more severe LV dysfunction and higher mortality rates within the first 6 months after the initial event. Thereafter, LV function has recovered completely in patients with typical and in those with atypical TTC resulting in a similar prognosis.

The distinctive LV contraction pattern with apical

Disclosures

The authors have no conflicts of interest to disclose.

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