Takotsubos cardiomyopathy is reported at an increasing frequency. Though it considered a diagnosis of exclusion it remains a pathology requiring focused investigation and tailored management. Despite its prevalence most clinicians do not seem to have a good grasp on the diagnosis and the management of this condition. There have been a large number of publications reporting the various aspects of this condition. Though a noxious emotional event seems to be the most commonly associated trigger, there are a large number of additional triggers that have been described. There are widely accepted diagnostic criteria. Different investigational modalities have different yields in supporting or excluding the diagnosis. The clinical course and the prognosis too can have significant variety. As far as the management strategy is concerned there is no widely accepted pathways published as yet. Clinicians are guided by the clinical condition and the circumstances of the event to decide on the optimal management strategy. We have attempted in this detailed review to collate as much published material as possible to give the clinician reader a sound global insight into this important cardiac condition.

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Aim: This study sought to evaluate the impact of device extraction on the severity of TR in patients with cardiac device related infection (CDI) and infective endocarditis (CDRIE). Methods: The medical and echocardiographic records of 142 patients who had undergone device extraction for suspected infection from 2007 - 2013 were reviewed. Data on clinical complications, echocardiographic documentation of TR severity prior to and after device removal and potential risk factors for change in TR severity was obtained. A paired t test was used to evaluate whether the TR mean grade changed significantly. Patient Demographics: A total of 56 patients out of the 142 patients had TTE and/or TOE imaging. Of these patients, 22 patients had ICD’s, 27 patients had PPM’s and 7 patients had BiV Devices. The mean age was 62 years (47 males). Clinical complications included decompensated heart failure (12.5%), septic shock (8.9%), septic arthritis (8.9%), splenic abscess (1.78%), septic pulmonary embolism (5.35%), leukocytoclastic vasculitis (1.78%). Results: The mean duration of device in situ prior to extraction was 64 months (5.33yrs). The mean grade of TR prior to device extraction was grade 1.35/4 (SD=0.901, C.I. 1.16 to 1.72). The mean grade of TR post extraction was 1.54/4 (SD= 0.96 with C.I. 1.26 to 1.89). The mean difference in mean TR grade was 0.13 (C.I. 0.37 to -0.106) p >0.05. One patient had a worsening of TR by at least 2 grades post extraction. This was due to valve perforation from infection rather than extraction related trauma. This was the only patient that required surgery for clinically significant TR. Risk factors for worsening TR post extraction included the length of time leads were in situ and age of the patient. Time of Device in situ prior to extraction did not correlate significantly with severity of TR post procedure rho 0.12 (p value = 0.45). Furthermore, age at the time of the procedure did not correlate with tricuspid regurgitation severity post extraction rho 0.21 (p value = 0.18). Conclusions: Worsening of TR post extraction is uncommon and is more likely due to valve destruction from infection rather than trauma to the valve during extraction. Furthermore, a number of complications occur peri-procedurally that impacts on patient outcomes.