Clinical History An 83 year-old woman with a history of anxiety/depression presented to the emergency room with fatigue and lethargy. Her presenting ECG demonstrated ST segment elevations in V2-V4, and her initial troponin was noted to be elevated. She was admitted with a presumed ongoing ST elevation myocardial infarction. However, she refused invasive coronary angiography, and was subsequently referred for a diagnostic cardiac CTA.
Cardiac CTA demonstrated normal coronary arteries without evidence of plaque or stenosis. Retrospective-gated functional images revealed left ventricular (LV) apical ballooning, consistent with Takotsubo cardiomyopathy. A subsequent transthoracic echocardiogram (TTE) confirmed the presence of an apical ballooning syndrome.
(Click on image to enlarge)
Figure 1:Cardiac CTA left ventriculogram demonstrates normal LV diastolic chamber contours and apical ballooning during systole.
Figure 3:Four-chamber TTE image showing segmental LV dysfunction involving the apical, distal anteroseptal, and distal anterior territories of the LV, without evidence of left ventricular thrombus.
Figure 4:3D Cardiac CTA surface-rendered images demonstrate normal appearing coronary arteries, without evidence of obstructive coronary artery disease.
Takotsubo cardiomyopathy is generally regarded as a form of transient stress cardiomyopathy1-2 and occurs predominantly in post-menopausal women. The presentation is variable, but often consists of chest pain, new ST elevations on a resting ECG, as well as modest elevations of cardiac biomarkers. In our case, cardiac CTA was able to assess coronary artery anatomy and cardiac function with a single non-invasive examination, and TTE confirmed the diagnosis of Takotsubo cardiomyopathy. Fortunately, as in our case, most patients experience a full recovery within a few weeks of supportive therapy, with a reported in-house mortality in the 1% range3.
Ryan, TJ and Fallon, JT. A 44-year-old woman with substernal pain and pulmonary edema after severe emotional stress. NEJM 1986; 314:1240-47.
Hurst RT, Prasad A, Askew JW 3rd, Sengupta PP, Tajik AJ. Takotsubo cardiomyopathy: a unique cardiomyopathy with variable ventricular morphology. JACC Cardiovasc Imaging. 2010; 3(6):641-9.
Gianni, M et al. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006; 27:1523-1529.
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Suhny Abbara, MD
MGH Department of Radiology
Wilfred Mamuya, MD, PhD
MGH Department of Cardiology