Takotsubo Cardiomyopathy: Assessment With Cardiac MRI

Transcription

1 Cardiopulmonary Imaging Pictorial Essay Fernández-Pérez et al. MRI of Takotsubo Cardiomyopathy Cardiopulmonary Imaging Pictorial Essay Gabriel C. Fernández-Pérez 1 José ntonio guilar-rjona 1 Gonzalo Tardáguila de la Fuente 1 Marcelo Samartín 2 lejandro Ghioldi 2 Juan Carlos rias 2 Javier Sánchez-González 3 Fernández-Pérez GC, guilar-rjona J, Tardáguila de la Fuente G, et al. Keywords: MRI, Takotsubo cardiomyopathy, transient left ventricular apical ballooning syndrome DOI: /JR Received July 15, 2009; accepted after revision February 2, J. Sánchez-González has a financial relationship with Philips Healthcare. 1 Department of Radiology, POVIS Hospital, Salamanca St., 5, 36211, Vigo, Pontevedra, Spain. ddress correspondence to G. C. Fernández-Pérez (gabriel.fdez.perez@gmail.com). 2 Department of Cardiology, POVIS Hospital, Vigo, Pontevedra, Spain. 3 Philips Healthcare, Madrid, Spain. JR 2010; 195:W139 W X/10/1952 W139 merican Roentgen Ray Society Takotsubo Cardiomyopathy: ssessment With Cardiac MRI OJECTIVE. The objective of this article is to show how MRI findings can be used to differentiate Takotsubo cardiomyopathy from acute coronary syndrome. CONCLUSION. Takotsubo cardiomyopathy is a disorder that mimics acute coronary syndrome. MRI can show not only edema in the ventricular wall, which is diffuse and without arterial territory distribution, but also motion abnormalities with typical akinesis in the apical and mid planes. Moreover, MRI can detect potential complications such as obstruction of the left ventricular outflow tract or thrombus in the left ventricular cavity. T akotsubo cardiomyopathy is a reversible cardiomyopathy, often precipitated by a stressful event, with clinical features practically indistinguishable from acute myocardial infarction. This disorder usually affects postmenopausal women and is characterized by hypokinesis or akinesis in the mid and apical segments of the left ventricular (LV) wall and typically spares the basal segments in the absence of obstructive coronary lesions. The prognosis is excellent with prompt recovery of LV function. Dote et al. [1] first described Takotsubo cardiomyopathy during left ventriculography, in which the heart looks like a takotsubo, typical Japanese pot used to catch octopi (Figs. 1 and 2; Fig. S2, which can be seen in the JR electronic supplement to this article, available at The modified Mayo Clinic diagnostic criteria for Takotsubo cardiomyopathy are, first, the presence of transient hypokinesis, akinesis, or dyskinesis in the LV mid and apical segments with wall motion abnormalities that extend beyond a single epicardial vascular distribution and frequently, but not always, of a stressful trigger; second, the absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; third, new ECG changes with ST-segment elevation or T-wave inversion and usually elevation of cardiac markers; and, fourth, the absence of pheochromocytoma and myocarditis [2]. Clinical Findings Takotsubo cardiomyopathy accounts for approximately 1 2% of all patients with suspected ST-segment elevation myocardial infarction (STEMI). Patients are usually postmenopausal women years old, but they can range in age from 10 to 91 years, although only a few cases have been reported in men and young people [2, 3]. Clinically, Takotsubo cardiomyopathy is similar to an acute coronary syndrome but frequently is preceded by a severe emotional or physically stressful event such as the death of a loved one, a quarrel, financial loss, automobile crash, and so on. However, in some cases, the precipitating stressor is not identified in the clinical history [2, 3]. Patients are often first seen in the emergency department for acute chest pain and show changes on ECG that mimic a STEMI. In more than 90% of the cases, ECG shows an anterior ST-segment elevation that posteriorly evolves to T- wave inversion with associated prolongation of the QT interval and transient anteroseptal Q waves (Fig. 3). Thus, no ECG change can be used to differentiate between anterior myocardial infarction and Takotsubo cardiomyopathy in the first moments. However, ECG findings are transient and disappear within the first weeks in most cases of Takotsubo cardiomyopathy. slight increase of cardiac enzyme levels also occurs in Takotsubo cardiomyopathy but is lower than expected in relation to extension of the ECG findings [3]. W139

2 TLE 1: MR Protocol in Patients With cute Chest Pain Fernández-Pérez et al. Plan the cardiac views lack-blood T2 STIR Protocol Sequences LV Plane Tips Cine balanced turbo echo gradient Cine balanced turbo echo gradient Perfusion Late enhancement Note LV = left ventricle. alanced turbo field echo, interactive or real time lack-blood triple inversion recovery alanced turbo echo gradient for functional images alanced turbo field echo for functional images In the context of clinical features, coronary angiography shows no significant atherosclerotic lesions in the epicardial arteries in almost all patients with Takotsubo cardiomyopathy. When left ventriculography or echocardiography is performed, apical or mid ventricular LV wall motion abnormalities are typically seen [4 6]. Several authors have used MRI to study patients with Takotsubo cardiomyopathy to show the presence or absence of necrosis in the stunned apical area using delayed contrast enhancement techniques [7 9]. In this setting and in the study of patients with acute chest pain, our institution uses a specific MRI protocol (Table 1) that emphasizes the T2 STIR sequence. MRI Findings T2 STIR Sequence In all cases of Takotsubo cardiomyopathy, the most characteristic finding is ventricular edema that appears as high signal intensity with a diffuse or transmural distribution. Moreover, the location of the edema is not related to a vascular territory of coronary arteries, and edema is distributed in both the apical and mid planes of the LV. The area of edema shows dysfunction in the ventricular contraction observed with cine MRI sequences (Fig. 4). These features can be used to differentiate Takotsubo cardiomyopathy from acute myocardial infarction, in which edema usually has a transmural effect on the LV wall but always has a vascular distribution (Fig. 5). cute myocarditis is also associated with alanced turbo field echo with saturation prepulse using T1 enhancing gadolinium (0.1 mmol/kg at 4 5 ml/s) Inversion-recovery turbo field echo 3D with an inversion prepulse and fat suppression Short-axis plane, vertical long-axis plane, and four-chamber view Short-axis plane (optional vertical long-axis plane and four-chamber view) Multiphase and slice covering the LV in short-axis plane Multiphase images in vertical long-axis plane, short-axis plane, and four-chamber view 3 6 slices can be acquired in short-axis plane during one R-R cycle depending on heart rate 10 slices can be obtained in a breath-hold (or with navigator); short-axis plane, vertical long-axis plane, and four-chamber view are recommended acute chest pain, increased cardiac biomarker levels, and ECG changes. In these patients, the T2 STIR sequence shows high signal intensity in the ventricular wall, but the distribution is more heterogeneous and frequently has a mid or subepicardial location. Vascular distribution of edema is not seen in Takotsubo cardiomyopathy. nother feature of Takotsubo cardiomyopathy is the relation of the T2 signal with the time since the initial symptoms. When MRI is performed in the first days after symptom onset, the T2 signal is very evident; however, 2 weeks after the onset of symptoms, the signal intensity decreases and in many cases can be difficult to differentiate from the signal intensity of the normal ventricular wall (Fig. 6). On the other hand, the T2 signal intensity of segments affected by STEMI is maintained for a longer time and, in many cases, is visible for more than 2 or 3 months after symptom onset. Similar findings occur in patients with acute myocarditis, and the presence of edema on MRI has been reported until 111 days (mean) after symptom onset (range, days) [8]. Cine MRI Cine MRI shows the contraction abnormalities in the ventricular wall affecting the mid and apical planes in all segments. The presence of apical akinesis produces the ballooning morphology of the LV that characterizes Takotsubo cardiomyopathy, resembling a Japanese pot used to capture octopi (Figs. 7 and S7, the latter of which can be seen in Fast and easy method to acquire the LV planes in real time Fat suppression enhances the edema hypersignal; note whether edema has a vascular location It allows assessment of the contractility and ejection fraction of LV One breath-hold per image is enough to estimate ejection fraction Perfusion defects with arterial segments location permits estimation of an occlusion or high-grade vascular stenosis Just after perfusion sequence, a second dose of contrast material (0.1 mmol/kg) is used; the signal of normal myocardium is suppressed the JR electronic supplement to this article, available at These findings are associated with a systolic ventricular dysfunction, which is severe in many patients, and results in an important reduction in the ejection fraction that produces clinical symptoms of heart failure and hemodynamic instability and even of cardiogenic shock in a minority of patients. However, systolic dysfunction is reversible and transient, and patients are usually discharged from the hospital with normal LV function (Fig. 8). nother finding suggestive of Takotsubo cardiomyopathy is the presence of hyperkinesis in the basal plane of the LV contributing to the characteristic morphology. Nevertheless, both basal hyperkinesis and mid apical akinesis can produce a dynamic obstruction in the LV outflow even with associated systolic anterior motion of the anterior mitral leaflet, which is similar to patients with hypertrophic obstructive cardiomyopathy (Fig. 9). n apical clot in the LV can be also seen using a cine MRI sequence and is another complication with potential to subsequently result in systemic embolism (Fig. 10). Contrast-Enhanced Sequence No LV segments show perfusion defects or late enhancement, and findings on these techniques are usually normal in patients with Takotsubo cardiomyopathy. However, perfusion defects and enhanced segments with vascular distribution are frequently observed in patients with STEMI (Fig. 11). On the other hand, late enhancement is usually seen in acute myo- W140

3 MRI of Takotsubo Cardiomyopathy carditis but occurs in a mid or subepicardial location in the LV, which differs from Takotsubo cardiomyopathy and ischemic disease. Discussion Takotsubo cardiomyopathy is characterized by transient abnormalities in wall motion involving the LV apex and mid ventricle in the absence of obstructed epicardial coronary arteries. The cause of Takotsubo cardiomyopathy is still unknown; however, several mechanisms have been proposed such as multivessel epicardial spasm, myocardial dysfunction induced by catecholamine damage, microvascular dysfunction in the absence of obstructive disease, and neurogenically mediated myocardial stunning. ECG abnormalities particularly ST-segment elevation in precordial leads and evolutionary T-wave inversion are detected [10]. Coronary angiography is the preferred method for examining patients with acute chest pain, ECG changes, and elevated cardiac enzyme levels. However, in patients with normal findings on coronary angiography, diagnosis can present a clinical dilemma because there are other causes of acute chest pain, ECG changes, and elevated cardiac enzyme levels such as acute myocarditis, myocardial infarction with a recanalized coronary artery, Takotsubo cardiomyopathy, or noncardiac causes. MRI is a noninvasive method that offers an opportunity to differentiate among these entities and identify the extension of inflammation in the ventricular wall. Reported MRI findings in Takotsubo cardiomyopathy are very limited in the radiology literature compared with the higher numbers of reports in the cardiology literature [9, 11]. Despite some isolated published cases describing small areas of late enhancement in the apical segment, MRI findings in Takotsubo cardiomyopathy are typically the absence of late enhancement on delayed contrast sequences, which differentiates Takotsubo cardiomyopathy from anterior STEMI in which necrosis in the wall is present in most patients even with no reflow or microvascular obstruction features [8]. The high intensity signal on T2-weighted imaging directly relates to the water content in the myocardial wall; in Takotsubo cardiomyopathy, edema is typically located in the apical mid ventricular planes, sparing the base plane, and matches the wall-motion abnormalities seen on cine MRI [8, 12]. The perfusion sequence in patients with Takotsubo cardiomyopathy usually is normal. However, a few reported cases have shown impaired myocardial perfusion and the authors concluded that this abnormal finding is owed to abnormal microvascular blood flow [13, 14]. Some of the complications of Takotsubo cardiomyopathy can be diagnosed using MRI. One complication is that dynamic obstruction of the LV outflow tract can produce instability and heart failure in patients with Takotsubo cardiomyopathy, so it is very important to detect this complication because treatment with β-blockers reduces contractility and increases end-systolic volume. Other rare but serious complications include thrombus formation in the LV because systemic thromboembolism can occur [15]. Moreover, in many cases, a small thrombus is underdiagnosed on ventriculography or even echocardiography, and MRI may contribute to the identification of the clot on both cine MRI and delayed contrast sequences in these patients. Thus, treatment with anticoagulation therapy decreases mortality in these patients. Conclusion MRI is a noninvasive imaging method that can provide useful information for the diagnosis of Takotsubo cardiomyopathy. The presence of diffuse edema in the LV wall located in the apical and mid planes and associated with akinesis hypokinesis in these segments are the most characteristic features of Takotsubo cardiomyopathy. lso, the absence of perfusion defects and delayed enhancement are other clues that differentiate Takotsubo cardiomyopathy from other diseases such as acute myocardial infarction and acute myocarditis. References 1. Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases. J Cardiol 1991; 21: kashi YJ, Goldstein DS, arbaro G, Ueyama T. Takotsubo cardiomyopathy: a new form of acute, reversible heart failure. Circulation 2008; 118: ybee K, Prasad. Stress-related cardiomyopathy syndromes. Circulation 2008; 118: Koeth O, Mark, Kilkowski, et al. Clinical, angiographic and cardiovascular magnetic resonance findings in consecutive patients with Takotsubo cardiomyopathy. Clin Res Cardiol 2008; 97: Mitchell JH, Hadden T, Wilson JM, chari, Muthupillai R, Flamm SD. Clinical features and usefulness of cardiac magnetic resonance imaging in assessing myocardial viability and prognosis in Takotsubo cardiomyopathy (transient left ventricular apical ballooning syndrome). m J Cardiol 2007; 100: Ibañez, Navarro F, Cordoba M, M-lberca P, Farre J. Tako-tsubo transient left ventricular apical ballooning: is intravascular ultrasound the key to resolve the enigma? Heart 2005; 91: Vallès E, Pujadas S, Guindo J, Leta R, Carreras F, Pons-Lladó G. Delayed-contrast enhancement cardioresonance in transient left ventricular apical ballooning. Int J Cardiovasc Imaging 2007; 23: ssomull RG, Lyne JC, Keenan N, et al. The role of cardiovascular magnetic resonance in patients presenting with chest pain, raised troponin, and unobstructed coronary arteries. Eur Heart J 2007; 28: Gerbaud E, Montaudon M, Leroux L, et al. MRI for the diagnosis of left ventricular apical ballooning syndrome (LVS). Eur Radiol 2008; 18: ybee K, Motiei, Syed IS, et al. Electrocardiography cannot reliably differentiate transient left ventricular apical ballooning syndrome from anterior ST-segment elevation myocardial infarction. J Electrocardiol 2007; 40:38.e1 e6 11. Cummings KW, halla S, Javidan-Nejad C, ierhals J, Gutierrez FR, Woodard PK. patternbased approach to assessment of delayed enhancement in nonischemic cardiomyopathy at MR imaging. RadioGraphics 2009; 29: Otsuka Y, Noguchi T, Goto Y, Nonogi H, Yamada N. Hyperintensity on T2-weighted magnetic resonance imaging in Takotsubo cardiomyopathy. Int J Cardiol 2008; 130: ruder O, Hunold P, Jochims M, Waltering KU, Sabin GV, arkhausen J. Reversible late gadolinium enhancement in a case of Takotsubo cardiomyopathy following high-dose dobutamine stress MRI. Int J Cardiol 2008; 127:e22 e Elesber, Lerman, ybee K, et al. Myocardial perfusion in apical ballooning syndrome correlate of myocardial injury. m Heart J 2006;152: 469.e9 e Singh V, Mayer T, Salanitri J, Salinger MH. Cardiac MRI documented left ventricular thrombus complicating acute Takotsubo syndrome: an uncommon dilemma. Int J Cardiovasc Imaging 2007; 23: W141

4 Fernández-Pérez et al. Fig. 1 Drawing shows takotsubo, a pot used to catch octopi in Japan. It is round at bottom and has narrow neck to keep octopus from escaping. Fig. 2 Left ventriculography in systole () and diastole () in 78-year-old woman with Takotsubo cardiomyopathy. In systole, apical akinesis and ballooning with marked hyperkinesis in basal plane (black line, ) are observed. Conventional angiography (not shown) showed normal epicardial coronary arteries. See cine MRI, Figure S2, in JR electronic supplement to this article, which is available at Fig. 3 ECG changes in 68-year-old woman with Takotsubo cardiomyopathy., Initial ECG shows minimal ST-segment elevation in V4 V6. Prolonged QT interval (QTc, 480 milliseconds) and incomplete right bundle branch block are also observed., One day after, ECG shows characteristic deep T-wave inversion in precordial leads (arrows). W142

5 MRI of Takotsubo Cardiomyopathy Fig. 4 T2 STIR sequence in 68-year-old woman in acute state of Takotsubo cardiomyopathy. Diffuse and transmural edema is observed in apical and mid planes of left ventricle. However, segments in basal plane have normal signal intensity. reas with edema show wall motion abnormalities in cine MRI. Fig year-old man with ST-segment elevation myocardial infarction. T2 STIR image reveals edema in anteroapical segments showing vascular territory is dependent on left anterior descending coronary artery (arrows). Fig year-old woman with Takotsubo cardiomyopathy., T2 STIR image obtained 48 hours after patient was admitted to emergency department. Edema is located in apical and mid planes of left ventricle (LV) without vascular distribution., T2 STIR image obtained 2 weeks after shows edema signal (arrows) is lower than that observed in initial examination. Systolic function of LV improved with recovery of ejection fraction and LV wall contraction. W143

6 Fernández-Pérez et al. Fig. 7 Vertical long axis in systolic and diastolic cine MR images from 78-yearold woman with Takotsubo cardiomyopathy. MRI was performed third day after onset of symptoms. pical akinesis produces apical ballooning, resembling Japanese takotsubo. See cine MRI, Figure S7, in JR electronic supplement to this article, which is available at Fig. 9 Complications in Takotsubo cardiomyopathy. Takotsubo cardiomyopathy in 73-year-old postmenopausal woman with reduced ejection fraction and slightly elevated cardiac enzymes (troponin I, 12.8 ng/ml; normal value < 0.15 ng/ml). Cine MRI in horizontal long-axis view shows systolic jet in left ventricular outflow tract (LVOT) due to dynamic obstruction of LVOT (arrow). This phenomenon can develop as result of dyskinetic apical and midventricular segments with hyperdynamic function of basal segments. LVOT obstruction is usually accompanied by mitral regurgitation. Fig. 8 Cine MR images from 78-year-old woman with Takotsubo cardiomyopathy (same patient as in Fig. 7), obtained on day 28, show recovery of wall contraction in apical segments. Systolic function of left ventricle is also normal. Fig. 10 Complications of Takotsubo cardiomyopathy in 68-year-old woman with apical thrombus. Horizontal long-axis () and four-chamber () views with cine MRI sequences show small apical clot (arrows, and ). Delayed enhancement in four-chamber (C) and apical short-axis (D) planes obtained 5 minutes after contrast administration shows left apical thrombus as nonenhanced round nodule (arrows, C and D). W144

7 MRI of Takotsubo Cardiomyopathy Fig year-old woman with Takotsubo cardiomyopathy (same patient as in Figs. 7 and 8). and, Delayed enhancement sequence in four-chamber () and two-chamber () views. Note absence of enhanced areas in left ventricular wall. FOR YOUR INFORMTION The data supplement accompanying this Web exclusive article can be viewed from the information box in the upper right corner of the article at: W145