Catecholamine-Induced Secondary Takotsubo Syndrome in Children With Severe Enterovirus 71 Infection and Acute Heart Failure: A 20-year Experience of a Single Institute

Sheng-Ling Jan; Yun-Ching Fu; Ching-Shiang Chi; Hsiu-Fen Lee; Fang-Liang Huang; Chung-Chi Wang; Hao-Ji Wei; Ming-Chih Lin; Po-Yen Chen; Betau Hwang

doi:10.3389/fcvm.2021.752232

Catecholamine-Induced Secondary Takotsubo Syndrome in Children With Severe Enterovirus 71 Infection and Acute Heart Failure: A 20-year Experience of a Single Institute

Front Cardiovasc Med. 2021 Sep 23:8:752232. doi: 10.3389/fcvm.2021.752232. eCollection 2021.

Authors

Sheng-Ling Jan^{1

2

3}, Yun-Ching Fu^{1

2}, Ching-Shiang Chi⁴, Hsiu-Fen Lee¹, Fang-Liang Huang¹, Chung-Chi Wang⁵, Hao-Ji Wei⁵, Ming-Chih Lin^{1

2}, Po-Yen Chen¹, Betau Hwang⁴

Affiliations

¹ Department of Pediatrics, Children's Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan.
² Department of Pediatrics, School of Medicine, National Yang-Ming University, Taipei, Taiwan.
³ Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan.
⁴ Department of Pediatrics, Tungs' Taichung Metroharbor Hospital, Taichung, Taiwan.
⁵ Department of Cardiovascular Surgery, Cardiovascular Medical Center, Taichung Veterans General Hospital, Taichung, Taiwan.

Abstract

Background: Acute heart failure (AHF) is the major cause of death in children with severe enterovirus 71 (EV71) infection. This study aimed to report our clinical experience with EV71-related AHF, as well as to discuss its pathogenesis and relationship to Takotsubo syndrome (TTS). Methods: A total 27 children with EV71-related AHF between 1998 and 2018 were studied. The TTS diagnosis was based on the International Takotsubo Diagnostic Criteria. Results: Acute heart failure-related early death occurred in 10 (37%) of the patients. Sinus tachycardia, systemic hypertension, and pulmonary edema in 100, 85, and 81% of the patients, respectively, preceded AHF. Cardiac biomarkers were significantly increased in most patients. The main echocardiographic findings included transient and reversible left ventricular (LV) regional wall motion abnormality (RWMA) with apical ballooning. High concentrations of catecholamines either preceded or coexisted with AHF. Myocardial pathology revealed no evidence of myocarditis, which was consistent with catecholamine-induced cardiotoxic damage. Patients with EV71-related AHF who had received close monitoring of their cardiac function, along with early intervention involving extracorporeal life support (ECLS), had a higher survival rate (82 vs. 30%, p = 0.013) and better neurological outcomes (59 vs. 0%, p = 0.003). Conclusion: EV 71-related AHF was preceded by brain stem encephalitis-related hypercatecholaminemia, which resulted in a high mortality rate. Careful monitoring is merited so that any life-threatening cardiogenic shock may be appropriately treated. In view of the similarities in their clinical manifestations, natural course direction, pathological findings, and possible mechanisms, TTS and EV71-related AHF may represent the same syndrome. Therefore, we suggest that EV71-related AHF could constitute a direct causal link to catecholamine-induced secondary TTS.

Keywords: Takotsubo syndrome; catecholamine; dilated cardiomyopathy; enterovirus 71; heart failure.