Cardiovascular magnetic resonance findings in typical versus atypical forms of the acute apical ballooning syndrome (Takotsubo cardiomyopathy)
Introduction
In 1991 Dote and colleagues [1] reported on an acute reversible heart injury syndrome which they called “tako-tsubo” (Japanese for octopus trap) cardiomyopathy because of similarity between the octopus trap with a round bottom and narrow neck and the end-systolic left-ventriculogram. The syndrome consists of a sudden onset of transient akinesia or dyskinesia of the apical and mid-portions of the left ventricle, without significant coronary artery stenosis, often accompanied by chest pain, dynamic reversible ST-T segment abnormalities, and elevation of cardiac enzymes disproportionate to the extent of akinesia [2]. Takotsubo cardiomyopathy (TTC) affects predominantly women and is often triggered by preceding emotional or physical stress [3]. Although the left ventricular (LV) apex is believed to be invariably affected [4], we were recently able to demonstrate that a variant form of the syndrome without involvement of the LV apex exists [5].
Diagnostic work up of patients with suspected TTC requires assessment of LV morphology and function as well as demonstration of reversibility of the initial wall motion abnormalities (WMA) on follow up examinations. These information can best be obtained by either echocardiography or cardiovascular magnetic resonance (CMR) imaging. We hypothesized that CMR might be superior to echocardiography in TTC, if it could provide additional information that would assist in differentiating this entity from other potentially reversible conditions with similar clinical presentations such as myocarditis or myocardial infarction. Early experience with gadolinium-enhanced CMR in a limited number of patients with TTC has demonstrated lack of myocardial hyperenhancement on delayed imaging [6], [7], [8], [9], [10], an observation that is different from findings in the majority of patients with myocarditis [11] or acute myocardial infarction [12]. This article reports on our experience with 17 consecutive patients.
Section snippets
Patients
From January 2004 to May 2005 17 patients presenting with an acute coronary syndrome were diagnosed with TTC and underwent gadolinium-enhanced cardiovascular magnetic resonance (CMR) at our institution. Of these, 7 have already been reported upon in previous publications by the same group [5], [13], [14]. Diagnosis of TTC was based upon the following criteria: 1) reversible akinesia or dyskinesia beyond a single major coronary artery vascular distribution on left ventriculography; 2) no
Clinical characteristics
There were 10 patients with classical TTC (9 women) and 7 patients with the variant form (6 women). Patients' data are presented in Table 1, Table 2. Fourteen patients presented with chest pain. Two patients were sedated prior to development of TTC and were unable to express any symptoms. In these patients TTC was discovered during diagnostic work up for sudden and unexplained hypotension. One patient presented with syncope. Mean age was 66 ± 13 years (range 41–82). Peak value for creatinine
Discussion
Prior reports of TTC have largely been confined to the Japanese population where it has been reported to account for 1% of admissions for suspected myocardial infarction [18]. Recently several series of the syndrome have been published outside Japan [2], [4], [5], [6], [7], [14], [19]. However, clinical experience with CMR in this entity is still limited. CMR findings have been reported in studies by Sharkey et al. [6] (n = 22 patients), Wittstein et al. [7] (n = 5 patients), Haghi et al. [5] (n = 4
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