Hemodynamic Effects, Safety, and Feasibility of Intravenous Esmolol Infusion During Takotsubo Cardiomyopathy With Left Ventricular Outflow Tract Obstruction: Results From A Multicenter Registry

Abstract

SUMMARYBackground: Left ventricular outflow tract obstruction (LVOTO) may complicate an episode of Takotsubo cardiomyopathy (TTC), potentially leading to cardiogenic shock. Betablockers are considered the most suitable treatment for such complication. Aim of the study: The objective of this study was to evaluate the hemodynamic effects, safety, and feasibility of a selective beta-blocker (b1) with a short half-life, esmolol, in subjects with a TTC episode. Methods: Ninety-six consecutive patients with TTC were enrolled in a multicenter registry. The hemodynamic and echocardiographic effects of esmolol (0.15-0.3 mg/kg/min) were analyzed in nine consecutive patients with LVOTO. Clinical course of patients, hemodynamics, days of hospitalization, LV function, and adverse events at follow-up were recorded. Results: Left ventricular outflow tract obstruction was present in 10 (10.4%) of 96 patients. Patients with LVOTO were older and had higher values of troponin-I at admission. LV ejection fraction at admission (36.1 AE 8.4%) significantly improved at discharge (51.4 AE 6.9%, P = 0.001). Among patients treated with esmolol infusion, LVOT pressure gradient before treatment was 47.6 AE 16.6 mmHg and after 18.2 AE 2.3 mmHg (P = 0.0091). Systolic blood pressure decreased from 123.8 AE 29.1 to 112.6 AE 12.7 mmHg (P = 0.1537). Mean hospital stay was 9 AE 2 days. No adverse events were observed during hospitalization and at follow-up. Conclusions: Esmolol infusion was temporally associated with reduction in intraventricular gradient and systemic blood pressure in patients with TTC and LVOTO. Further controlled studies are warranted to confirm these preliminary findings.

Impella in Takotsubo syndrome complicated by left ventricular outflow tract obstruction and severe mitral regurgitation

“…The recognition of LVOTO prompted us to stop dobutamine infusion and to place an MCS device . In fact, catecholamine might worsen cardiogenic shock by increasing the intraventricular gradient and should be avoided in this clinical scenario . Moreover, the coexistence of moderate‐to‐severe MR and the pulmonary congestion discouraged intravenous fluid infusion, which may be beneficial in patients with LVOTO in absence of severe acute heart failure.…”

“…In fact, despite some authors hypothesize a beneficial effect of beta-blockers for treatment of LVOTO complicating TTS, these drugs are not indicated in patients with acute heart failure and severe hypotension. 12,13 Despite the absence of specific recommendation by established guidelines, the use of MCS device has been recently suggested for the management of TTS patients with severe hypotension. 12 Venoarterial extracorporeal membrane oxygenation does not seem a valid option because it reduces LV preload and may even increase the LVOTO.…”

Management of Takotsubo Syndrome: A Comprehensive Review

“…A total of 4,313 articles were found of which 248 articles met the inclusion criteria. Based on predefined criteria, only 16 of these articles were included in this review ( Table 1) [5][6][7][8][9][10][11][12][13][14][15][16][17][18][19][20].…”

Tachycardia and hypotension in patients with takotsubo syndrome: any insights about their management?

“…Care would be exercised to ascertain whether the HR was in response to underlying heart failure (and thus served a physiological purpose), or to hypovolaemia (and thus fluid administration could lead to reduction of the high HR). The choice of beta‐blockers, dose, and their route of administration will need to be evaluated, and such therapy could be considered for the majority of patients with TTS, and not only for patients with complicated left ventricular outflow tract obstruction. Also continuous monitoring of the role of the heightened activity of the autonomic sympathetic nervous system on the high HR might be of value in future studies.…”