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62 | Letters to the Editor
International Cardiovascular Forum Journal 5 (2016)
DOI: 10.17987/icfj.v5i0.260
Immersion Pulmonary Edema in the Setting
of Takotsubo Cardiomyopathy
Tara Reed1, Dante Sorrentino,2 Steven Azuma.3
1. University of Hawaii John A. Burns School of Medicine .
2. University of Hawaii Internal Medicine Residency Program.
3.Assistant Clinical Professor University of Hawaii John A. Burns School of Medicine, Kuakini Medical Center,
Queens Medical Center Honolulu, HI
Corresponding author:
Tara Reed,
1241 Rycroft St. #301, Honolulu, HI 96814
Email: [email protected]
Keywords:
Pulmonary edema; acute coronary syndrome; takotsubo cardiomyopathy; apical ballooning; immersion
Citation:
Reed T, Sorrentino D, Azuma S. Immersion Pulmonary Edema in the Setting of Takotsubo Cardiomyopathy.
International Cardiovascular Forum Journal. 2016;5:62-63. DOI: 10.17987/icfj.v5i0.260
Immersion Pulmonary Edema (IPE) is a unique medical condition
being increasingly described in the medical literature as suddenonset pulmonary edema in the setting of scuba diving and/or
swimming. We report on three patients with unique presentations
of IPE with associated development of Takotsubo cardiomyopathy
(TTC). All three cases occurred in Oahu, Hawaii and were seen by
the same cardiologist within a span of seven years.
Each patient was scuba diving with sudden onset dyspnea with
pulmonary edema on chest x-ray. Cardiac catheterization revealed
no significant epicardial stenosis or thrombosis. EKGs showed
typical evolution of symmetric T wave inversion. Wall motion
abnormalities resolved. IPE and TTC may occur together and may
be more common than initially thought. Physical and emotional
stressors are known to trigger TTC. TTC should be considered
as a possible complication of IPE. Initial workup should include
EKGs, cardiac enzymes, echocardiogram and, in the appropriate
situation, cardiac catheterization.
Takotsubo cardiomyopathy (TTC) was first described in Japan in
1991, named for the unique left ventricular morphological features.1,2
Takotsubo is a Japanese word that translates to “octopus pot.”
Also known as Apical Ballooning Syndrome and Broken Heart
Syndrome, TTC is a type of acquired stress cardiomyopathy. This
syndrome is now being increasingly recognized in the literature
and the American Heart Association has formally incorporated this
disease in the class of acquired cardiomyopathies. Usually seen
in perimenopausal or menopausal women, TTC is stimulated by a
type of emotional or physical stress.4 Presentation often mimics
ST-Elevation Myocardial Infarction, but without significant coronary
artery stenosis. Based on retrospective studies, approximately
2% of all patients with suspected acute coronary syndrome were
found to have TTC.3,4
There is no consensus on diagnostic criteria for TTC. The Mayo
Clinic proposed diagnostic criteria in 2004 and this has been
commonly adopted throughout the literature.5 This criterion is
used by the International Takotsubo Registry (InterTAK Registry).
* Corresponding author. E-mail: [email protected]
Scuba divers’ pulmonary edema (SDPE) is a unique medical
condition being increasingly described in the medical literature
as sudden-onset pulmonary edema in the setting of scuba
diving. SDPE is one type of Immersion Pulmonary Edema (IPE),
which presents with shortness of breath, tachypnea, fatigue, and
cough with frothy white or blood-tinged sputum.6
A 62-year-old Italian-Mexican female was in her normal state
of health prior to a dive where she followed appropriate ascent
rates of no more than one foot every two seconds (30ft/9m per
minute) and made necessary decompression stops. On ascent,
she experienced dyspnea and cough. When she reached the
surface, she was given an oxygen mask and coughed up white
frothy fluid with blood-tinged sputum. There was no aspiration of
seawater, chest pain, or palpitations.
She initially presented with an oxygen saturation of 82% on nonrebreather oxygen mask. Her lung examination was significant
for diffuse bilateral rhonchi. Electrocardiogram showed deep
pathologic Q waves in V1, V2, and V3 and T wave inversions
in lead I, aVL, and V6. Initial troponin I value was 0.69 ug/L and
peaked at 0.84 ug/L. Other significant lab values on admission
were Creatine Kinase 523 U/L, Brain Natriuretic Peptide (BNP) 570
ng/L, and mild leukocytosis. Transthoracic echocardiogram (TTE)
showed an ejection fraction of 32% and severe global hypokinesis
of the left ventricle. She underwent left heart catheterization,
selective coronary arteriography, and left ventriculography.
There was no evidence of coronary artery disease. There were
findings of apical ballooning with hyperkinetic base supportive
of TTC (Figure 1). Her ejection fraction at that time was 45%
measured by planimetry. The patient was discharged home in
stable condition. One month later, she had a repeat TTE. There
were no wall motion abnormalities, apical hypokinesis or apical
ballooning. Ejection fraction improved to 55%.
The next patient is a 60-year-old Caucasian male with no history of
coronary artery disease and was in his normal state of health prior
to the dive. When he reached the water’s surface, he was dyspneic
ISSN: 2410-2636 © Barcaray Publishing
International Cardiovascular Forum Journal 5 (2016)
DOI: 10.17987/icfj.v5i0.260
a)
Letters to the Editor | 63
b)
Figure 1. Left heart catheterization was performed. The above ventriculography showed apical ballooning with hyperkinetic base
supportive of TCM a) diastole b) systole.
and immediately began coughing up brown-tinged foamy sputum.
There was no aspiration of seawater, chest pain, or palpitations.
The patient led an active lifestyle and had a negative treadmill
stress test (12 minutes on Bruce protocol) done two months prior.
On admission, his Creatine Kinase-MB (CK-MB) was 4.7 ng/ml,
Troponin-I 0.04 ug/L, BNP 137 ng/L. Troponin-I peaked at 0.53 ug/L
and CK-MB levels at 8.7 ng/ml. Chest x-ray showed pulmonary
edema suggestive of congestive heart failure. Electrocardiogram
showed regular sinus rhythm with no ST or T wave changes. TTE
showed a severe deterioration of left ventricular ejection fraction to
25% with global hypokinesis in his left chamber with characteristic
apical ballooning. Subsequent cardiac catheterization showed an
estimated ejection fraction of 60% with mild anterior hypokinesis
and no significant coronary artery disease. The patient was
discharged the next day in stable condition.
The third patient is a 47-year-old Japanese female who ascended
per diving protocol and was noted to be hyperventilating. She
successfully surfaced, but lost consciousness while boarding
the vessel. Oxygen saturation was found to be 88% on room
air on arrival to the hospital. On admission, her CK-MB was 39
ng/ml, Troponin-I 0.49 ug/L, BNP 46 ng/L. Troponin-I peaked
at 3.49 ug/L. Echocardiogram revealed normal sinus rhythm
with mild increase in QTC to 479, left ventricular hypertrophy,
1-mm ST elevations in leads V1, V2, and V3, ST depressions in
leads V4, V5, and V6, and T wave inversions in lead V2. Chest
x-ray was significant for bilateral mild to moderate infiltrates.
TTE showed an ejection fraction of 45% with diminished left
ventricular compliance. Left heart cardiac catheterization
revealed an anterior and inferior severe hypokinesis with
diminished ejection fraction around 45%. There were no
significant coronary calcifications found. She was discharged
two days after admission in stable condition.
The overall prognosis of TTC remains excellent, with a full recovery
observed in 96% of cases although serious complications do
occur, including ventricular rupture, thrombosis, arrhythmia, and
chronic heart failure.8
In all three cases above, the physical stress of acute pulmonary
edema likely triggered TTC. SDPE is a unique etiology of acute
pulmonary edema discussed in the literature. One study by Coulange
et al. examined 22 patients that had IPE with no underlying cardiac
disease.7 They found that symptoms of IPE consistently started
during the ascent to the water’s surface.7 At six-month followup, all patients were found to have normal respiratory function,
echocardiograms, and exercise tolerance tests.7
This case series presents the possibility of TTC induced by IPE
without any underlying cardiac disease. All three cases occurred
in Oahu, Hawaii and were seen by the same cardiologist within
a span of seven years. In this case series, minimal intervention
was performed with complete resolution of symptoms and full
restoration of cardiac function. IPE and TTC may be more common
than initially thought. In the setting of scuba diving, IPE may be the
initiating factor of the reversible cardiac dysfunction seen in TTC.
TTC should be considered as a possible complication of IPE.
Declarations of Interest
The authors declare no conflicts of interest.
Acknowledgements
The authors state that they abide by the “Requirements for
Ethical Publishing in Biomedical Journals”.9
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