Forensic Science, Medicine, and Pathology

, Volume 11, Issue 4, pp 577–583 | Cite as

Takotsubo cardiomyopathy associated with rupture of the left ventricular apex: assessment of histopathological features of a fatal case and literature review

  • Francesca Indorato
  • Yoshihiro J. Akashi
  • Carlo Rossitto
  • Cataldo Raffino
  • Giovanni Bartoloni
Case Report


Takotsubo cardiomyopathy, also known as “broken heart syndrome,” is a cardiac entity characterized by transient left ventricular dysfunction without obstructive atherosclerotic coronary artery disease. An episode of emotional stress is believed to act as a trigger in the development of this syndrome, which typically occurs in female patients. We report a fatal case of a previously healthy 70-year-old woman who suffered an out-of-hospital cardiac arrest and cardiac rupture during emotional distress, due to Takotsubo cardiomyopathy. Ventricular rupture with Takotsubo cardiomyopathy is rare, but our case emphasizes the importance of dealing with this serious and potentially life-threatening disease. Takotsubo cardiomyopathy should be considered as a differential diagnosis in cases of early-developing heart failure, and clinicians should subsequently use adequate diagnostic and therapeutic options.


Takotsubo cardiomyopathy Ventricular rupture Stress cardiomyopathy Emotional stress 


  1. 1.
    Sharkey SW, Lesser JR, Maron MS, Maron BJ. Why not just call it tako-tsubo cardiomyopathy: a discussion of nomenclature. J Am CollCardiol. 2011;57:1496–7.CrossRefGoogle Scholar
  2. 2.
    Maron BJ, Towbin JA, Thiene G, Antzelevitch C, Corrado D, Arnett D, et al. Contemporary definitions and classification of the cardiomyopathies: an American Heart Association scientific statement from the Council on Clinical Cardiology, Heart Failure and Transplantation Committee; Quality of Care and Outcomes Research and Functional Genomics and Translational Biology Interdisciplinary Working Groups; and Council on Epidemiology and Prevention. Circulation. 2006;113:1807–16.CrossRefPubMedGoogle Scholar
  3. 3.
    Eshtehardi P, Koestner SC, Adorjan P, Windecker S, Meier B, Hess OM, et al. Transient apical ballooning syndrome-clinical characteristics, ballooning pattern, and longterm follow-up in a Swiss population. Int J Cardiol. 2009;135:370–5.CrossRefPubMedGoogle Scholar
  4. 4.
    Wedekind H, Möller K, Scholz KH. Tako-tsubo cardiomyopathy (Incidence in patients with acute coronary syndrome). Herz. 2006;31:339–46.CrossRefPubMedGoogle Scholar
  5. 5.
    Akashi YJ, Nakazawa K, Kida K, et al. Reversible ventricular dysfunction (takotsubo cardiomyopathy) following polymorphic ventricular tachycardia. Can J Cardiol. 2003;19:449–51.PubMedGoogle Scholar
  6. 6.
    Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, et al. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med. 2004;141:858–65.CrossRefPubMedGoogle Scholar
  7. 7.
    Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 2008;155:408–17.CrossRefPubMedGoogle Scholar
  8. 8.
    Kawai S, Kitabatake A, Tomoike H. Guidelines for diagnosis of takotsubo (ampulla) cardiomyopathy. Circ J. 2007;71:990–2.CrossRefPubMedGoogle Scholar
  9. 9.
    Eitel I, von Knobelsdorff-Brenkenhoff F, Bernhardt P, Carbone I, Muellerleile K, Aldrovandi A, et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy. JAMA. 2011;306:277–86.PubMedGoogle Scholar
  10. 10.
    Pilgrim TM, Wyss TR. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review. Int J Cardiol. 2008;124:283–92.CrossRefPubMedGoogle Scholar
  11. 11.
    Kumar S, Kaushik S, Nautiyal A, et al. Cardiac rupture in takotsubo cardiomyopathy: a systematic review. ClinCardiol. 2011;34:672–6.Google Scholar
  12. 12.
    Liang JJ, Cha YM, Oh JK, Prasad A. Sudden cardiac death: an increasingly recognized presentation of apical ballooning syndrome (Takotsubo cardiomyopathy). Heart Lung. 2013;42:270–2.CrossRefPubMedGoogle Scholar
  13. 13.
    Lyon AR, Rees PS, Prasad S, Poole-Wilson PA, Harding SE. Stress (Takotsubo) cardiomyopathy-a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med. 2008;5:22–9.CrossRefPubMedGoogle Scholar
  14. 14.
    Wittstein IS, Thiemann DR, Lima JA, Baughman KL, Schulman SP, Gerstenblith G, et al. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 2005;352:539–48.CrossRefPubMedGoogle Scholar
  15. 15.
    Abraham J, Mudd JO, Kapur NK, Klein K, Champion HC, Wittstein IS. Stress cardiomyopathy after intravenous administration of catecholamines and beta-receptor agonists. J Am Coll Cardiol. 2009;53:1320–5.CrossRefPubMedGoogle Scholar
  16. 16.
    Akashi YJ, Nef HM, Lyon AR. Epidemiology and pathophysiology of Takotsubo syndrome. Nat Rev Cardiol. 2015;12:387–97.CrossRefPubMedGoogle Scholar
  17. 17.
    Nef HM, Möllmann H, Kostin S, Troidl C, Voss S, Weber M, et al. Tako- Tsubo cardiomyopathy: intraindividual structural analysis in the acute phase and after functional recovery. Eur Heart J. 2007;28:2456–64.CrossRefPubMedGoogle Scholar
  18. 18.
    Khullar M, Datta BN, Wahi PL, Chakravarti RN. Catecholamine-induced experimental cardiomyopathy—a histopathological, histochemical and ultrastructural study. Indian Heart J. 1989;41:307–13.PubMedGoogle Scholar
  19. 19.
    Morel O, Sauer F, Imperiale A, Cimarelli S, Blondet C, Jesel L, et al. Importance of inflammation and neurohumoral activation in Takotsubo cardiomyopathy. J Card Fail. 2009;15:206–13.CrossRefPubMedGoogle Scholar
  20. 20.
    Eitel I, Lücke C, Grothoff M, Sareban M, Schuler G, Thiele H, et al. Inflammation in takotsubo cardiomyopathy: from cardiovascular magnetic resonance imaging. Eur Radiol. 2010;20:422–31.CrossRefPubMedGoogle Scholar
  21. 21.
    Syed FF, Asirvatham SJ, Francis J. Arrhythmia occurrence with Takotsubo cardiomyopathy: a literature review. Europace. 2011;13:780–8.CrossRefPubMedGoogle Scholar
  22. 22.
    Reich P. Psychological predisposition to life-threatening arrhythmias. Annu Rev Med. 1985;36:397–405.CrossRefPubMedGoogle Scholar
  23. 23.
    Akashi YJ, Sakakibara M, Miyake F. Reversible left ventricular dysfunction “takotsubo” cardiomyopathy associated with pneumothorax. Heart. 2002;87:E1.PubMedCentralCrossRefPubMedGoogle Scholar
  24. 24.
    Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Sasaka K. Reversible left ventricular dysfunction “takotsubo” cardiomyopathy related to catecholamine cardiotoxicity. J Electrocardiol. 2002;35:351–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Abe Y, Kondo M, Matsuoka R, Araki M, Dohyama K, Tanio H. Assessment of clinical features in transient left ventricular apical ballooning. J Am Coll Cardiol. 2003;41:737–42.CrossRefPubMedGoogle Scholar
  26. 26.
    Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Koike J, Sasaka K. The clinical features of takotsubo cardiomyopathy. QJM. 2003;96:563–73.CrossRefPubMedGoogle Scholar
  27. 27.
    Kuo BT, Choubey R, Novaro GM. Reduced estrogen in menopause may predispose women to takotsubo cardiomyopathy. Gend Med. 2010;7:71–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Ueyama T, Hano T, Kasamatsu K, Yamamoto K, Tsuruo Y, Nishio I. Estrogen attenuates the emotional stress-induced cardiac responses in the animal model of Tako-tsubo (Ampulla) cardiomyopathy. J Cardiovasc Pharmacol. 2003;42(Suppl 1):S117–9.CrossRefPubMedGoogle Scholar
  29. 29.
    Elesber AA, Prasad A, Lennon RJ, Wright RS, Lerman A, Rihal CS. Four-year recurrence rate and prognosis of the apical ballooning syndrome. J Am Coll Cardiol. 2007;50:448–52.CrossRefPubMedGoogle Scholar
  30. 30.
    Sharkey SW, Windenburg DC, Lesser JR, Maron MS, Hauser RG, Lesser JN, et al. Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J Am Coll Cardiol. 2010;55:333–41.CrossRefPubMedGoogle Scholar
  31. 31.
    Elsokkari I, Cala A, Khan S, Hill A. Takotsubo cardiomyopathy: not always innocent or predictable. A unique post mortem insight. Int J Cardiol. 2013;167(2):e46–e48.Google Scholar

Copyright information

© Springer Science+Business Media New York 2015

Authors and Affiliations

  • Francesca Indorato
    • 1
  • Yoshihiro J. Akashi
    • 2
  • Carlo Rossitto
    • 3
  • Cataldo Raffino
    • 3
  • Giovanni Bartoloni
    • 1
  1. 1.Department “GF Ingrassia”, Section of Legal MedicineUniversity of CataniaCataniaItaly
  2. 2.Division of Cardiology, Department of Internal MedicineSt. Marianna University School of MedicineKawasakiJapan
  3. 3.Diagnostic PathologyGaribaldi Nesima HospitalCataniaItaly

Personalised recommendations