Focal Takotsubo Cardiomyopathy- Insights from Cardiac MRI Imaging

Abstract

Case: A previously well 62-year-old female presented to the emergency department with central chest pain following an argument. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2. She underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis. Left ventriculography demonstrated focal dyskinesis of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiac magnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig. 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig. 1). The findings were thought to be most consistent with a focal Takotsubo cardiomyopathy (TC). Repeat TTE 1 month later demonstrated complete normalisation of LV contraction. Discussion: TC is a rare syndrome characterised by transient regional systolic dysfunction of the LV, mimicking myocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial oedema in 81% patients, and no significant LGE in 91%.