Tako-Tsubo Cardiomyopathy / Transient LV Apical Ballooning Syndrome

History: 69 year-old female with no known history of CAD presented to ER with substernal severe chest pain following an emotional stress. She was diagnosed with acute myocardial infarction with positive cpk and troponin. Cardiac catheterization revealed normal coronaries. A Cardiac MRI was performed immediately following the MI and in 3 months after discharge.

 

Technique: Short and radial FIESTA images were acquired to assess left ventricular function and morphology. Contrast-enhanced delayed images were done to assess for myocardial infarction.

 

Findings:

The function study (top row) acquired after MI was consistent with hypokinesis of the anterior wall. The follow-up study done 3 months later revealed complete resolution of the wall motion abnormality. Importantly, the MDE images (bottom row) showed no infarct in the hypokinetic territory at the time of the presentation. The presence of a wall motion abnormality without an infarct is consistent with stunned myocardium which recovered as evident by the follow-up study.

 

Discussion:

The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy, is characterized by transient apical wall-motion abnormalities and the absence of obstructive coronary artery disease. This syndrome usually affects post-menopausal women presenting with signs and symptoms of acute myocardial infarction in the setting of significant emotional or physiologic stress. The shape of the ventricle on the ventriculogram and the absence of obstructive epicardial coronary disease on catheterization are characteristic (tako-tsubo (jap.) = octopus pot).

The prognosis is favorable – most patients recover ventricular function in few weeks. The etiology of the syndrome is unknown, but is thought to be related to a neuro-hormonal spasm of the epicardial vessel (particularly left anterior descending artery) leading to myocardial stunning.

 

References:

Wittstein IS, et al.  Neurohumoral Features of Myocardial Stunning Due to Sudden Emotional Stress NEJM  2005; 352:539-548

 

Bybee KA, et al.  Systematic Review: Transient Left Ventricular Apical Ballooning: A Syndrome That Mimics ST-Segment Elevation Myocardial Infarction. Ann Intern Med  2004; 141:858-865

 

History: 77 year-old female with no known history of CAD presented to PMD`s office with mild shortness of breath on exertion. Patient reported having a loss in the family 2 weeks ago and has been emotionally distressed. The echocardiogram done at the doctor`s office showed wall motion abnormalities and decreased EF. Cardiac catheterization done based on the echo findings revealed normal coronaries. A Cardiac MRI was performed a week following the echocardiogram to assess for LV function and viability.

 

Technique: Short and radial FIESTA images were acquired to assess left ventricular function and morphology. Contrast-enhanced delayed images were done to assess for myocardial infarction.

 

Findings:

The function study (top row) acquired was consistent with global hypokinesis of the midventricle – sparing the septum, and akinesis of the apex. The wall motion at the base was normal (first 2 slices of the top row). Importantly, the MDE images (bottom row) showed no infarct in the hypokinetic territory. The presence of a wall motion abnormality without an infarct is consistent with stunned myocardium. The patient will have a follow-up study done in the future to see if there is improvement in the LV function.

 

Discussion:

The transient left ventricular apical ballooning syndrome, also known as takotsubo cardiomyopathy, is characterized by transient apical wall-motion abnormalities and the absence of obstructive coronary artery disease. This syndrome usually affects post-menopausal women presenting with signs and symptoms of acute myocardial infarction in the setting of significant emotional or physiologic stress.