Cardiovascular magnetic resonance findings in typical versus atypical forms of the acute apical ballooning syndrome (Takotsubo cardiomyopathy)

Abstract

To assess cardiovascular magnetic resonance (CMR) findings in Takotsubo cardiomyopathy (TTC), 17 consecutive patients (15 women) with TTC who underwent left heart catheterization and gadolinium-enhanced CMR were evaluated. All patients had an abnormal electrocardiogram consisting of ST-segment elevation (n = 8) and/or ST-segment depression (n = 4) and/or T-wave inversion (n = 14). One patient presented with left-bundle branch block. Left ventricular apical segments were involved in 10 patients (classical TTC), while they were not affected in 7 (variant form). Mean time delay between presentation and CMR was 9 ± 7 days (range 3–24 days). CMR demonstrated complete resolution (n = 4) or significant improvement of initial WMA in all cases. WMA were confined to basal and mid-ventricular segments (segments 1–12 in the 17-segment model) in the variant form, while they were virtually confined to the mid and apical left ventricle (segments 7–17) in classical TTC. Upon presentation ejection fraction by ventriculography was lower in classical TTC (36 ± 7% vs. 58  ± 8%, p = 0.0001). However, upon follow up ejection fraction by CMR was not different between classical and variant TTC (49 ± 9% vs. 56 ± 11%, p = 0.23). Delayed hyperenhancement was absent in all but one patient. This finding may help differentiate TTC from entities with similar clinical presentations such as myocarditis and myocardial infarction, as the latter typically exhibits a subendocardial pattern of delayed hyperenhancement while the former usually displays a patchy subepicardial pattern.

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.