Echocardiography in stress cardiomyopathy and acute LVOT obstruction. Int J Cardiovasc Imaging. 2010;26:527-535. [PMID: 20119847 DOI: 10.1007/s10554-010-9590-7]

Role of Imaging in Cardiomyopathies

Imaging has a central role in the diagnosis, classification, and clinical management of cardiomyopathies. While echocardiography is the first-line technique, given its wide availability and safety, advanced imaging, including cardiovascular magnetic resonance (CMR), nuclear medicine and CT, is increasingly needed to refine the diagnosis or guide therapeutic decision-making. In selected cases, such as in transthyretin-related cardiac amyloidosis or in arrhythmogenic cardiomyopathy, the demonstration of histological features of the disease can be avoided when typical findings are observed at bone-tracer scintigraphy or CMR, respectively. Findings from imaging techniques should always be integrated with data from the clinical, electrocardiographic, biomarker, genetic and functional evaluation to pursue an individualised approach to patients with cardiomyopathy.

Establishment and effect evaluation of a stress cardiomyopathy mouse model induced by different doses of isoprenaline

The optimum dose of isoprenaline (ISO) required to induce stress cardiomyopathy (SC) in mice is not known. The present study aimed to investigate the dose-response association and determine the optimum dose of ISO to establish a high-morbidity/low-mortality SC mouse model to simulate the clinical symptoms of SC. A total of 72 6-week-old wild-type female mice (C57BL/6) were randomly divided into control mice administered normal saline and mice treated with increasing ISO concentrations (5, 10, 25, 50 and 100 mg/kg ISO intraperitoneal injections daily for 14 consecutive days). All mice were analysed by body weight assessment, open field test (OFT), echocardiography (Echo), electrocardiogram (ECG), assessment of myocardial pathology and quantification of cortisol, brain natriuretic peptide (BNP), cardiac troponin T (cTnT), catecholamine (CA) and C-reactive protein (CRP). Compared with the control group, the 25 and 50 mg/kg ISO groups exhibited the most prominent weight changes and lower mortality. The open-field test showed a significant decrease in autonomous activity behaviour in the 25 and 50 mg/kg ISO groups compared with the control group (P<0.05). Echo revealed that the apex of the heart was balloon-like in the 25 and 50 mg/kg ISO groups, along with prominent left ventricular dyskinesia. ECG showed a significant increase in ST segment amplitude, QT interval and Q amplitude (P<0.05) in the 25 and 50 mg/kg ISO group compared with the control group. Haematoxylin and eosin staining of heart tissue showed a disordered arrangement of myocardial cells, dissolution of myocardial fibres and cytoplasm, notable widening of myocardial cell space, oedema and hyperaemia of the interstitium, whereas heart tissue of the control group was structurally intact. Compared with the control group, the 25 and 50 mg/kg ISO groups exhibited significantly higher levels of cortisol, BNP, cTNT, CA and CRP (P<0.05). A high-incidence low-mortality SC model was successfully and stably developed by administration of 25 and 50 mg/kg ISO. Such models may provide a basis for the development of other animal models of SC.

Stepwise approach for diagnosis and management of Takotsubo syndrome with cardiac imaging tools

Takotsubo syndrome is featured by transient left ventricle dysfunction in the absence of significant coronary artery disease, mainly triggered by emotional or physical stress. Its clinical presentation is similar to acute coronary syndrome; therefore, cardiac imaging tools have a crucial role. Coronary angiography is mandatory for exclusion of pathological stenosis. On the other side, transthoracic echocardiography is the first non-invasive imaging modality for an early evaluation of left ventricle systolic and diastolic function. Left ventricle morphologic patterns could be identified according to the localization of wall motion abnormalities. Moreover, an early identification of potential mechanical and electrical complications such as left ventricle outflow tract obstruction, mitral regurgitation, thrombus formation, right ventricular involvement, cardiac rupture, and cardiac rhythm disorders could provide additional information for clinical management and therapy. Because of the dynamic evolution of the syndrome, comprehensive serial echocardiographic examinations should be systematically performed. Advanced techniques, including speckle-tracking echocardiography, cardiac magnetic resonance, and nuclear imaging can provide mechanistic and pathophysiologic insights into this syndrome. This review focuses on these aspects and provide a stepwise approach of all cardiac imaging tools for the diagnosis and the management of Takotsubo syndrome.

Review of multi-modality imaging update and diagnostic work up of Takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TC) is an acute but reversible non-ischemic heart failure syndrome. It is characterized by a transient form of ventricular dysfunction typically manifesting as basal hyperkinesis with hypokinesia and ballooning of left ventricle mid-cavity and apex. Imaging helps in both diagnosis and follow up. Echocardiogram is the first-line modality to assess the typical contractile dysfunction in suspected patients with catheter angiography showing normal coronary arteries. Cardiac MRI is currently the modality of choice for the non-invasive initial assessment of TC and for follow up imaging. The current review focusses on historical background of TC, its pathophysiology, diagnostic work up and differential diagnosis and provides multimodality imaging work up of TC including role of echocardiogram, invasive catheterization, nuclear imaging, cardiac computed tomography and cardiac MRI including basic and advanced MRI sequences.

Usefulness of Stress Echocardiography in Assessment of Dynamic Left Ventricular Obstructions: Case Series and Review of the Literature

Dynamic left ventricular outflow tract obstruction (DLVOTO) or midcavity obstruction in patients with structurally normal hearts is not uncommon in routine clinical practice and can cause significant symptoms mimicking coronary artery disease or heart failure. Although exercise echocardiography is the gold standard for assessing DLVOTO, dobutamine stress echocardiography (DSE) may be valuable diagnostic modality in patients who are unable to exercise or have an uninterpretable 12-lead electrocardiogram. We provide an updated overview of the relevant literature regarding prevalence, pathophysiology, clinical significance, and prognostic impact of DLVOTO and midcavity obstruction in structurally normal hearts. We also present a clinical series of 4 cases of DLVOTO and midcavity obstruction documented by DSE and discuss the value of different kinds of modern stress imaging modalities involving: (1) contrast-enhanced DSE to assess myocardial perfusion and inducible ischemia; (2) adenosine stress echocardiography to assess coronary flow reserve/microvascular dysfunction; and (3) functional imaging with deformation echocardiography to assess subclinical myocardial dysfunction in patients with structurally normal heart and without significant coronary disease. Based upon our own experiences and a critical review of the current literature, we will then present a practical guidance for management of DLVOTO and midcavity obstruction.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

A case of ultrashort-acting beta-blocker landiolol hydrochloride for takotsubo syndrome with left ventricular outflow tract obstruction

Takotsubo syndrome (TTS) has been known to have a favorable prognosis. Beta-blockers are reported to be effective for TTS patients with cardiogenic heart failure due to left ventricular outflow tract (LVOT) obstruction. However, there is no report on ultrashort-acting beta-blockers being used for treating TTS, and there are no clear guidelines for their dosages or applications. Herein, we describe a 72-year-old woman in whom landiolol hydrochloride was used in the acute phase of TTS with LVOT obstruction. In this case, the dose of landiolol hydrochloride was increased to 10 μg/kg/min, resulting in improvement of LVOT obstruction, which led to hemodynamic stabilization.

Characterising the Clinical Spectrum, Diagnosis and Outcomes in Secondary Stress Cardiomyopathy

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Role of echocardiography for takotsubo cardiomyopathy: clinical and prognostic implications

Takotsubo cardiomyopathy (TTC) is newly-described secondary cardiomyopathy characterized by transient left ventricular (LV) dysfunction, which is increasingly recognized in the field of cardiology. TTC occurs in approximately 2% of the patients with acute coronary syndrome. Its onset is rare; however, its specific features play a crucial role in diagnosing the chest pain in clinical practice. TTC has generally favorable outcome with rapid recovery of LV function; however, an increasing evidence suggests that it should be regarded as a more serious acute cardiac disorder with a variety of complications. Owing to its widespread availability, even in emergency settings, transthoracic echocardiography plays a key role in the diagnostic assessment of TTC and contributes to an increased number of disease detection and incidence reports in contemporary clinical practice. This review focuses on the role of echocardiography in understanding the clinical prognostic implications in patients with TTC.

A Case Report of Recurrent Takotsubo Cardiomyopathy in a Patient during Myasthenia Crisis

Introduction

Patients with myasthenia crisis can develop Takotsubo stress cardiomyopathy (SC) due to emotional or physical stress and high level of circulating catecholamines. We report a patient who developed recurrent Takotsubo cardiomyopathy during myasthenia crisis. Coexisting autoimmune disorders known to precipitate stress cardiomyopathy like Grave's disease need to be evaluated.

Case Report

A 69-year-old female with seropositive myasthenia gravis (MG), Grave's disease, and coronary artery disease on monthly infusion of intravenous immunoglobulin (IVIG), prednisone, pyridostigmine, and methimazole presented with shortness of breath and chest pain. Electrocardiogram (ECG) showed ST elevation in anterolateral leads with troponemia. Coronary angiogram was unremarkable for occlusive coronary disease with left ventriculogram showing reduced wall motion with apical and mid left ventricle (LV) hypokinesis suggestive of Takotsubo stress cardiomyopathy. Her symptoms were attributed to MG crisis. Her symptoms, ECG, and echocardiographic findings resolved after five cycles of plasma exchange (PLEX). She had another similar episode one year later during myasthenia crisis with subsequent resolution in 10 days after PLEX.

Conclusion

Takotsubo cardiomyopathy can be one of the manifestations of myasthenia crisis with or without coexisting Grave's disease. These patients might benefit from meticulous fluid status and cardiac monitoring while administering rescue treatments like IVIG and PLEX.

Coronary artery disease detection - limitations of stress testing in left ventricular dysfunction

Incidental diagnosis of left ventricular systolic dysfunction (LVD) is common in clinical practice. The prevalence of asymptomatic LVD (Ejection Fraction, EF < 50%) is 6.0% in men and 0.8% in women and is twice as common as symptomatic LVD. The timely and definitive exclusion of an ischemic etiology is central to optimizing care and reducing mortality in LVD. Advances in cardiovascular imaging provide many options for imaging of patients with left ventricular dysfunction. Clinician experience, patient endurance, imaging modality characteristics, cost and safety determine the choice of testing. In this review, we have compared the diagnostic utility of established tests - nuclear and echocardiographic stress testing with newer techniques like coronary computerized tomography and cardiac magnetic resonance imaging and highlight their inherent limitations in patients with underlying left ventricular dysfunction.

Stress cardiomyopathy of the critically ill: Spectrum of secondary, global, probable and subclinical forms

Stress cardiomyopathy (SC) typically presents as potential acute coronary syndrome (ACS) in previously healthy people. While there may be physical or mental stressors, the initial symptom is usually chest pain. This form conforms to the published Mayo diagnostic criteria, is well reported and as the presentation is initially cardiac, is considered primary SC. Increasingly we see SC develop several days into the hospitalization secondary to medical or surgical critical illness. This condition is more complex, presents atypically, is not easy to recognize and carries a much worse prognosis. Label of Secondary SC is appropriate as it manifests in sicker hospitalized patients with numerous comorbidities. We review the limited but provocative literature pertinent to SC in the critically ill and describe important clues to identify global, subclinical and probable forms of SC. We illustrate the several unique clinical features, demographic differences and propose a diagnostic algorithm to optimize cardiac care in the critically ill.

Contemporary Imaging in Takotsubo Syndrome

Transthoracic echocardiography is the first-line imaging modality for evaluating patients with Takotsubo syndrome (TTS). Beyond diagnosis, TTE enables detection of peculiar complications and is useful for risk stratification and management of patients with cardiogenic shock. Cardiac magnetic resonance can be used to detect myocardial edema typically associated with TTS and is helpful in the differential diagnosis with other disease states. Coronary computed tomography angiography can be performed as an alternative to coronary angiography to confirm coronary artery patency. Molecular imaging is a promising approach for identifying patients at increased risk of recurrence.

Standard and advanced echocardiography in takotsubo (stress) cardiomyopathy: clinical and prognostic implications

Echocardiography is frequently the initial noninvasive imaging modality used to assess patients with takotsubo cardiomyopathy (TTC). Standard transthoracic echocardiography can provide, even in the acute care setting, useful information about left ventricular (LV) morphology as well as regional and global systolic or diastolic function. It allows the differentiation of different LV morphologic patterns according to the localization of wall motion abnormalities. A "circumferential pattern" of LV myocardial dysfunction characterized by symmetric wall motion abnormalities involving the midventricular segments of the anterior, inferior, and lateral walls should be considered suggestive of TTC and included in the differential diagnosis of acute coronary syndromes. Moreover, advanced echocardiographic techniques, including speckle-tracking, myocardial contrast, and coronary flow studies, are providing mechanistic and pathophysiologic insights into this unique syndrome. Early identification of any potential complications (i.e., LV outflow tract obstruction, reversible moderate to severe mitral regurgitation, right ventricular involvement, thrombus formation, and cardiac rupture) are crucial for the management, risk stratification, and follow-up of patients with TTC. Because of the dynamic evolution of the syndrome, comprehensive serial echocardiographic examinations should be systematically performed. This review focuses on these aspects of imaging and the increasing understanding of the clinical and prognostic utility of echocardiography in TTC.

Relationship between acute strain pattern and recovery in tako-tsubo cardiomyopathy and acute anterior myocardial infarction: a comparative study using two-dimensional longitudinal strain

After acute-anterior myocardial infarction (AMI), left ventricular (LV) viable myocardial segments show some degree of active deformation (longitudinal shortening) despite wall motion abnormalities (WMA). Tako-tsubo cardiomyopathy (TTC) is characterized by myocardial stunning; however, it is unclear whether in TTC the strain pattern mimics AMI. To compare the strain-pattern in TTC and AMI using the 2D-longitudinal strain by speckle-tracking in segments with WMA, and its relationship with recovery of function at follow-up. 21 consecutive patients with typical TTC and 21 age-matched AMI patients treated by primary angioplasty had an analysis of LV-longitudinal strain at the acute-phase and at follow-up (1 and 6 months later for TTC and AMI respectively). The recovery of a segment was defined as normal wall motion at follow-up. Among the 706 analyzable LV-segments at the acute-phase, 406 had WMA (TTC 229, AMI 177). At follow-up, total recovery was observed for 45 % segments in AMI and 100 % in TTC, (p < 0.01). At the acute phase, systolic lengthening duration (47 ± 43 vs. 18 ± 33 %) and amplitude (0.25 ± 0.29 vs. 0.09 ± 0.19) and post systolic shortening (67 ± 53 vs. 39 ± 38 %) were higher in TTC, when compared to AMI-recovery (all, p < 0.01). In AMI, systolic lengthening duration was an independent predictor of poor recovery in multivariate analysis, linked to segmental longitudinal strain at follow-up (all, p ≤ 0.01). Furthermore, among the 57 % of segments exhibiting any systolic lengthening duration in AMI, only ¼ recovered, versus 62 % of such segments in TTC with 100 % recovery (p < 0.001). The systolic passive motion which is closely and inversely linked to recovery in AMI is paradoxically frequent and severe in TTC. This suggests that myocardial stunning in TTC and AMI is different according to longitudinal strain.

Takotsubo cardiomyopathy after transcatheter Edwards Sapien pulmonary valve placement in a patient with tetralogy of Fallot

A 34-year-old woman who had history of repaired tetralogy of Fallot with absent pulmonary valve syndrome presented for transcatheter intervention to reestablish pulmonary valve competence. A 26-mm Edwards Sapien valve was implanted, and coronary angiography after implantation demonstrated no coronary compression. Hemodynamically stable ventricular tachycardia was documented after the procedure. A 12-lead electrocardiogram showed ST segment elevation, and cardiac enzymes were moderately elevated. An echocardiogram demonstrated the stable position of the new pulmonary valve, the marked circumferential hypokinesia of the mid-to-apical left ventricular myocardium, and the normally contracting basal-to-mid myocardial segments. No intervention was required. An echocardiogram obtained 4 days after discharge showed qualitatively improved left ventricular systolic function, particularly in the apical region.

Brain-heart crosstalk: the many faces of stress-related cardiomyopathy syndromes in anaesthesia and intensive care

Neurogenic stress cardiomyopathy (NSC) is a well-known syndrome complicating the early phase after an acute brain injury, potentially affecting outcomes. This article is a review of recent data on the putative role of localization and lateralization of brain lesions in NSC, cardiac innervation abnormalities, and new polymorphisms and other genetic causes of the sympathetic nervous system over-activity. Concerns regarding the management of stress-related cardiomyopathy syndromes during the perioperative period are also discussed. Future clinical research should explore whether specific factors explain different patient susceptibilities to the disease and should be directed towards early identification and stratification of patients at risk, so that such patients can be more carefully monitored and appropriately managed in critical care and during the perioperative period.

Role of echocardiography in takotsubo cardiomyopathy

Takotsubo cardiomyopathy (TTC) is characterized by transient and reversible left ventricular (LV) systolic dysfunction due to extended myocardial stunning. Despite a good long term prognosis, approximately one-third of patients with TTC experience life-threatening complications during the acute phase. Echocardiography is the first imaging modality for an early evaluation of LV systolic and diastolic function in patients with TTC. Moreover, echocardiography allows the detection of specific findings associated with TTC, such as LV outflow tract obstruction, mitral regurgitation, and right ventricular involvement, providing crucial information for clinical management and therapy and for monitoring myocardial function recovery during the follow-up.

Takotsubo cardiomyopathy in a patient with lung adenocarcinoma

Takotsubo cardiomyopathy (TC) is a rare and usually physical or emotional stress-induced clinical disorder characterized by transient left ventricular dysfunction and apical segment ballooning. Much is still unknown regarding risk factors and clinical relationships. Recently, an association between TC and malignancies has been proposed. We present a case of lung adenocarcinoma whose initial hospital admission was due to TC. We contribute this case report to the growing set of literature on the association between TC and malignancies.

Echocardiographic assessment of regional left ventricular wall motion abnormalities in patients with tako-tsubo cardiomyopathy: comparison with anterior myocardial infarction

AIMS

The aim of this study was to assess the echocardiographic distribution of regional wall motion abnormalities (RWMA) in patients with tako-tsubo cardiomyopathy (TTC) compared with anterior ST-elevation myocardial infarction (ant-STEMI).

METHODS AND RESULTS

Thirty-seven TTC and 37 ant-STEMI patients underwent standard echocardiographic examination at the time of hospital admission. RWMA and the involvement of the left ventricular territories supplied by each coronary artery according to the American Society of Echocardiography classification were reported. TTC patients showed a lower left ventricular ejection fraction (37.6 ± 5.1 vs. 40.9 ± 3.7%; P = 0.002) and a higher wall motion score index (WMSI; 1.98 ± 0.2 vs. 1.51 ± 0.14; P < 0.001) compared with ant-STEMI patients. No significant differences were observed between groups with regard to detection of RWMA in the territory supplied by the left anterior descending coronary artery (LAD) (37 vs. 37; P = 1). Conversely, in TTC patients, the territories supplied by the LAD/left circumflex coronary artery (LCX) (37 vs. 31; P = 0.011), LAD/right coronary artery (RCA) (34 vs. 13; P < 0.001), RCA (33 vs. 5; P < 0.001), and RCA/LCX (31 vs. 2; P < 0.001) were more frequently involved. A cut-off value of WMSI ≥1.75 (area under the curve 0.956) and for the number of territories with RWMA ≥4 (AUC = 0.928) predicted TTC with a sensitivity of 83 and 84% and a specificity of 100 and 97%, respectively.

CONCLUSION

Echocardiography revealed a distinctive pattern of contractility in TTC patients, characterized by symmetrical RWMA extending equally into the territory of distribution of all coronary arteries.

Left ventricular outflow tract and mid-cavity obstruction may cause false-positive dobutamine stress echocardiograms

Left ventricular (LV) outflow tract obstruction (LVOTO) occurs in up to 20% of patients undergoing dobutamine stress echocardiography (DSE). Mid-cavity LV obstruction occurs less commonly during DSE. LV regional wall motion abnormalities during DSE may occur despite normal coronaries due to hypertensive blood pressure response and takotsubo stress cardiomyopathy. We describe herein two cases of LVOTO and one case of mid-cavity LV obstruction during DSE associated with transient apical hypokinesis.