State-of-the-Art Review Article
Standard and Advanced Echocardiography in Takotsubo (Stress) Cardiomyopathy: Clinical and Prognostic Implications

https://doi.org/10.1016/j.echo.2014.08.020Get rights and content

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.

Section snippets

LV Systolic Function

In the acute phase, transthoracic echocardiography (TTE) usually identifies the characteristic LV morphology associated with TTC. Standard TTE allows the detection of the different LV morphologic patterns according to the localization of wall motion abnormalities (WMAs).14, 15, 16 In the majority of cases, WMA typically involve the apical and midventricular segments, which appear akinetic or dyskinetic (defined as “apical ballooning”) in contrast to the basal segments, which are often

Myocardial Deformation Imaging

The profound transient LV dysfunction seen in TTC disturbs LV mechanics as well (Figure 6, Figure 7, Figure 8). Most data on myocardial deformation imaging in TTC are provided by two-dimensional strain with speckle-tracking echocardiography,30, 51, 52, 53, 54, 55 which allows the assessment of multidirectional LV deformation due to the complex myocardial architecture (longitudinal and circumferential shortening, radial thickening, and twisting).56 During the acute phase, there is a

Diagnostic Algorithm

Echocardiography may play a key role in the diagnostic workup of patients with TTC (Figure 13). In patients presenting with chest pain and/or dyspnea and ST-segment elevation on electrocardiography, emergency coronary angiography to exclude coronary occlusion or the presence of culprit lesions and left ventriculography are highly recommended. Conversely, in selected patients predisposed to develop TTC (postmenopausal women, those with trigger events) with no ST-segment elevation on

Conclusions

Echocardiography is generally the most practical diagnostic imaging technique for the majority of patients suspected of having TTC. Because of its dynamic and unique nature, comprehensive serial examinations should be systematically performed. Standard echocardiography can identify important distinctive features of TTC (Table 3). Advanced echocardiographic techniques, including speckle-tracking, myocardial contrast, and coronary flow studies, are providing further mechanistic and

References (87)

  • R. Citro et al.

    Clinical and echocardiographic correlates of acute heart failure, cardiogenic shock and in-hospital mortality: insights from the “Tako-Tsubo Italian Network”

    JACC Cardiovasc Imaging

    (2014)
  • V. Kurowski et al.

    Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis

    Chest

    (2007)
  • N. Mansencal et al.

    Apical-sparing variant of tako-tsubo cardiomyopathy: prevalence and characteristics

    Arch Cardiovasc Dis

    (2010)
  • F.O. Nascimento et al.

    Usefulness of the troponin-ejection fraction product to differentiate stress cardiomyopathy from ST-segment elevation myocardial infarction

    Am J Cardiol

    (2014)
  • C. Dib et al.

    Clinical correlates and prognostic significance of electrocardiographic abnormalities in apical ballooning syndrome (takotsubo/stress-induced cardiomyopathy)

    Am Heart J

    (2009)
  • T.M. Pilgrim et al.

    Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review

    Int J Cardiol

    (2008)
  • M. Madhavan et al.

    Acute heart failure in apical ballooning syndrome (takotsubo/stress cardiomyopathy): clinical correlates and Mayo Clinic risk score

    J Am Coll Cardiol

    (2011)
  • C. de Gregorio et al.

    Left ventricular thrombus formation and cardioembolic complications in patients with takotsubo-like syndrome: a systematic review

    Int J Cardiol

    (2008)
  • R. Citro et al.

    Role of echocardiography in takotsubo cardiomyopathy

    Heart Fail Clin

    (2013)
  • C.W. Good et al.

    Echocardiographic guidance in treatment of cardiogenic shock complicating transient left ventricular apical ballooning syndrome

    J Am Coll Cardiol Img

    (2009)
  • D.W. Donker et al.

    Rescue extracorporeal life support as a bridge to reflection in fulminant stress-induced cardiomyopathy

    Int J Cardiol

    (2012)
  • R. El Mahmoud et al.

    Prevalence and characteristics of left ventricular outflow tract obstruction in tako-tsubo syndrome

    Am Heart J

    (2008)
  • G. Parodi et al.

    Left ventricular apical ballooning syndrome as a novel cause of acute mitral regurgitation

    J Am Coll Cardiol

    (2007)
  • R. Citro et al.

    Right ventricular involvement and pulmonary hypertension in an elderly woman with tako-tsubo cardiomyopathy

    Chest

    (2010)
  • K. Liu et al.

    “Reverse McConnell’s sign?”: a unique right ventricular feature of Takotsubo cardiomyopathy

    Am J Cardiol

    (2013)
  • M. Hanna et al.

    Extent of right and left ventricular focal wall-motion abnormalities in differentiating transient apical ballooning syndrome from apical dysfunction as a result of coronary artery disease

    J Am Soc Echocardiogr

    (2007)
  • A.A. Elesber et al.

    Transient cardiac apical ballooning syndrome: prevalence and clinical implications of right ventricular involvement

    J Am Coll Cardiol

    (2006)
  • T.P. Fitzgibbons et al.

    Prevalence and clinical characteristics of right ventricular dysfunction in transient stress cardiomyopathy

    Am J Cardiol

    (2009)
  • N. Mansencal et al.

    Usefulness of two-dimensional speckle tracking echocardiography for assessment of tako-tsubo cardiomyopathy

    Am J Cardiol

    (2009)
  • V. Mor-Avi et al.

    Current and evolving echocardiographic techniques for the quantitative evaluation of cardiac mechanics: ASE/EAE consensus statement on methodology and indications endorsed by the Japanese Society of Echocardiography

    J Am Soc Echocardiogr

    (2011)
  • J.Y. Jang et al.

    Serial assessment of left ventricular remodeling by measurement of left ventricular torsion using speckle tracking echocardiography in patients with acute myocardial infarction

    Am J Cardiol

    (2010)
  • S.M. Park et al.

    Left ventricular systolic and diastolic function in patients with apical ballooning syndrome compared with patients with acute anterior ST-segment elevation myocardial infarction: a functional paradox

    Mayo Clin Proc

    (2009)
  • M. Grabowski et al.

    Real-time three-dimensional echocardiography in transient left apical ballooning syndrome

    Int J Cardiol

    (2008)
  • S. Schoof et al.

    Takotsubo cardiomyopathy in a 2-year-old girl: 3-dimensional visualization of reversible left ventricular dysfunction

    J Am Coll Cardiol

    (2010)
  • P. Meimoun et al.

    The coronary flow reserve is transiently impaired in tako-tsubo cardiomyopathy: a prospective study using serial Doppler transthoracic echocardiography

    J Am Soc Echocardiogr

    (2008)
  • R. Citro et al.

    Sequential transthoracic ultrasound assessment of coronary flow reserve in a patient with tako-tsubo syndrome

    J Am Soc Echocardiogr

    (2006)
  • S.S. Abdelmoneim et al.

    Microvascular function in takotsubo cardiomyopathy with contrast echocardiography: prospective evaluation and review of literature

    J Am Soc Echocardiogr

    (2009)
  • Y. Abe et al.

    Assessment of clinical features in transient left ventricular apical ballooning

    J Am Coll Cardiol

    (2003)
  • S. Kurisu et al.

    Myocardial perfusion and fatty acid metabolism in patients with tako-tsubo-like left ventricular dysfunction

    J Am Coll Cardiol

    (2003)
  • C. Burgdorf et al.

    Regional alterations in myocardial sympathetic innervation in patients with transient left-ventricular apical ballooning (tako-tsubo cardiomyopathy)

    J Nucl Cardiol

    (2008)
  • K. Obunai et al.

    Metabolic evidence of myocardial stunning in takotsubo cardiomyopathy: a positron emission tomography study

    J Nucl Cardiol

    (2005)
  • M. Feola et al.

    Reversible inverse mismatch in transient left ventricular apical ballooning: perfusion/metabolism positron emission tomography imaging

    J Nucl Cardiol

    (2006)
  • P. Meimoun et al.

    Non invasive coronary flow reserve is a powerful independent predictor of in-hospital complications in tako-tsubo syndrome

    Arch Cardiovasc Dis Suppl

    (2011)
  • Cited by (92)

    • Is Tako-tsubo cardiomyopathy really reversible ?

      2022, Annales de Cardiologie et d'Angeiologie
    • Review of multi-modality imaging update and diagnostic work up of Takotsubo cardiomyopathy

      2021, Clinical Imaging
      Citation Excerpt :

      Both systolic and diastolic left ventricle dysfunction have been reported in TC.59,60 TTE can also evaluate for right ventricle involvement and TC complications.59,61,62 Right ventricle involvement also known as reverse McConnell's sign with apical akinesis and basal hyperkinesia can be seen unlike McConnell's sign in acute massive pulmonary embolism.63

    • Takotsubo Cardiomyopathy—Navigating the Challenges of Diagnosis and Management in Heart Transplantation

      2021, Journal of Cardiothoracic and Vascular Anesthesia
      Citation Excerpt :

      There are several unique aspects of TTS that can facilitate successful management. Echocardiographic evaluation can detect associated complications, such as left ventricular outflow tract obstruction and apical thrombus, which occur most frequently due to apical ballooning in “typical” TTS.59,60 Serial echocardiographic assessment also can guide the management of these complications, as well as track the trajectory of ventricular recovery in TTS to inform prognosis and titration of selected therapies.59,60

    View all citing articles on Scopus
    View full text