Medical Image of the week: ECHO findings of Apical Ballooning Syndrome

  Figure 1. Panel A: Four chamber view of the heart at the end of diastole with a dilated left ventricle. Panel B: Same four chamber view of the heart at the end of systole with a dilation and akinesis of the apical portion (arrow) of the heart consistent with apical ballooning/stress cardiomyopathy

A 79 year old man with a history of lung cancer. bladder cancer, chronic obstructive pulmonary disease, and coronary artery disease with two previous myocardial infarctions, presented to the emergency department with respiratory failure secondary to pulmonary edema. Further evaluation was significant for non-ST segment elevation myocardial infarction. Cardiac catheterization was remarkable for a focal, eccentric 95% stenosis of the proximal to mid left anterior descending artery that failed stenting due to extensive calcifications. An echocardiogram (ECHO, Figure 1) revealed an ejection fraction of 47% with akinesis of the mid to distal anterior, lateral, inferior, septal and apical segments consistent with takotsubo cardiomyopathy.

Takotsubo cardiomyopathy, aka apical ballooning syndrome or stress induced cardiomyopathy, is a subtype of heart failure typically defined by proposed criteria from the Mayo Clinic that includes: 1. transient hypokinesis, akinesis, or dyskinesis in the left ventricular mid segments with or without apical involvement frequently occurring, but not always, in context to a stressful trigger; 2. the absence of angiographic evidence of obstructive coronary disease or plaque rupture; 3. new ECG abnormalities (ST-segment elevation and/or T-wave inversion) or modest elevation in cardiac troponin; and 4. the absence of pheochromocytoma and myocarditis (1). It predominantly occurs in post-menopausal women in relation to unexpected emotional or physical stress. Characteristic ECHO findings demonstrate a symmetrical regional wall motion abnormalities extending equally into the apical inferior and lateral wall with overall global hypokinesia (Figure 1) (2).

Sachin Kalarn MSIV; Sophie Galson MD; Kristina Skinner DO; Ryan Nahapetian MD, MPH

University of Arizona

Tucson, AZ

References

1. Akashi YJ, Goldstein DS, Barbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation. 2008;118(25):2754-62. [CrossRef] [PubMed]
2. Chockalingam A, Xie GY, Dellsperger KC. Echocardiography in stress cardiomyopathy and acute LVOT obstruction. Int J Cardiovasc Imaging. 2010;26(5):527-35. [CrossRef] [PubMed]

Reference as: Kalarn S, Galson S, Skinner K, Nahapetian R. Medical image of the week: ECHO findings of aprical ballooning syndrome. Southwest J Pulm Crit Care. 2015;10(4):150-1. doi: http://dx.doi.org/10.13175/swjpcc024-15 PDF

Medical Image of the Week: REM without Atonia

Figure 1. Polysomnogram with thirty-second epoch showing leg movements and relative increase in chin tone during REM sleep.

Figure 2. Polysomnogram with thirty-second epoch demonstrating similar interval of REM without atonia with the addition of sleep-talking.

A 78 year-old man with a past medical history of Parkinson’s disease (PD) presented to the sleep medicine clinic for evaluation of obstructive sleep apnea (OSA). An overnight polysomnogram (PSG) study was consistent with sleep apnea and revealed frequent leg and arm movements and sleep-talking during rapid eye movement (REM) sleep.

REM sleep behavior disorder (RBD) is a parasomnia characterized by repeated episodes of abnormal behavior occurring during REM sleep (1,2). On PSG, REM sleep without atonia is seen while features of “normal REM” such as number of REM periods and REM cycling remain intact (2). RBD emerges most often in the context of alpha-synucleinopathies, and occurs in up to 60% of PD patients (3). The presence of RBD may be an important preclinical symptom prior to the onset of PD. Cases of PD with RBD are associated with a unique phenotype with an older age of onset, longer disease duration, more profound motor disability, and greater degrees of hallucinations and cognitive dysfunction (3). Establishing a safe sleep environment can be of primary importance in patients with RBD as REM without atonia is associated with injurious behavior. Melatonin is effective as a first-line agent in patients with dementia. In non-demented patients without OSA, low-dose clonazepam is the first line intervention and is rarely associated with withdrawal or need for dose escalation (1). Treating concomitant OSA is important adjunctive therapy.

Jared Bartell, Safal Shetty MD, and Kenneth S. Knox MD

University of Arizona Medical Center

Tucson, AZ

References

1. Aurora RN, Zak RS, Maganti RK, Auerbach SH, Casey KR, Chowdhuri S, Karippot A, Ramar K, Kristo DA, Morgenthaler TI; Standards of Practice Committee; American Academy of Sleep Medicine. Best practice guide for the treatment of REM sleep behavior disorder (RBD). J Clin Sleep Med. 2010;6(1):85-95. [PubMed]
2. Schenck CH, Mahowald MW. REM sleep behavior disorder: clinical, developmental, and neuroscience perspectives 16 years after its formal identification in SLEEP. Sleep. 2002;25(2):120-38. [PubMed]
3. Kim YE, Jeon BS. Clinical implication of REM sleep behavior disorder in Parkinson's disease. Parkinsons Dis. 2014;4(2):237-44. [CrossRef] [PubMed]

Reference as: Bartell J, Shetty S, Knox KS. Medical image of the week: REM without atonia. Southwest J Pulm Crit Care. 2015;10(3):147-8. doi: http://dx.doi.org/10.13175/swjpcc022-15 PDF