Abstract
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-acutephase.
Highlights
Takotsubo syndrome (TTS), known as takotsubo cardiomyopathy, stress-induced cardiomyopathy, or apical ballooning syndrome, is an acute and transient heart failure syndrome originally reported by Dr Sato in 1991 in a Japanese textbook and by Pavin et al in Europe in 1997 [1, 2]
Neuroendocrine, metabolic, genetic, and inflammatory factors via increased adrenergic stimulation and high level of catecholamine release seem to be involved in the genesis of the reversible myocardial stunning associated with this fascinating syndrome [3]
The InterTAK diagnostic criteria have been developed [3] that incorporate several different aspects: (i) right ventricular (RV) involvement and other atypical wall motion abnormalities (WMAs); (ii) emotional or physical stress are no longer mandatory features; (iii) neurological disorders and pheochromocytoma are considered as potential triggers for TTS; and (iv) the possibility of coexisting significant coronary artery disease and TTS has been confirmed (Table 2)
Summary
Takotsubo syndrome (TTS), known as takotsubo cardiomyopathy, stress-induced cardiomyopathy, or apical ballooning syndrome, is an acute and transient heart failure syndrome originally reported by Dr Sato in 1991 in a Japanese textbook and by Pavin et al in Europe in 1997 [1, 2]. The InterTAK diagnostic criteria have been developed [3] that incorporate several different aspects: (i) right ventricular (RV) involvement and other atypical wall motion abnormalities (WMAs); (ii) emotional or physical stress are no longer mandatory features; (iii) neurological disorders and pheochromocytoma are considered as potential triggers for TTS; and (iv) the possibility of coexisting significant coronary artery disease and TTS has been confirmed (Table 2). The ‘apical nipple’ sign, a very small zone with preserved contractility of the LV apex, has been described on left ventriculography in about 30% of patients with TTS and typical apical ballooning (Fig. 2) [23] This sign can be a useful additional tool to discriminate TTS from acute anterior STEMI, in which the phenomenon is not observed. Given the technical complexity and high costs, the application of these tools should be considered only in selected cases with unclear or inconclusive angiographic findings
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