Usefulness of MRI in takotsubo cardiomyopathy: a review of the literature

Abstract

Takotsubo cardiomyopathy (TC) is a disease that can be misinterpreted as a more serious acute coronary syndrome. Its clinical characteristics resemble those of a myocardial infarct, while its imaging characteristics are critical on correctly characterizing and diagnosing the disease. From angiography, where coronary anatomy is evaluated, to cardiac magnetic resonance (CMR), where morphology and tissue characterization is assessed, the array of imaging options is quite extent. In particular, CMR has achieved great improvements (stronger magnetic fields, better coils, etc.) in the last decade which in turn has made this imaging technology more attractive in the evaluation and diagnosis of TC. With its superior soft tissue resolution and dynamic imaging capabilities, CMR is currently, perhaps, the most useful imaging technique in TC as apical ballooning or medio-basal wall motion abnormalities (WMA), presence of wall edema and late gadolinium enhancement (LGE) characteristics are critical in the diagnosis and characterization of this pathology. In this review, CMRs role in TC will be evaluated in light of the current available evidence in medical literature, while also revising the clinical and physiopathologic characteristics of TC.

Keywords: Broken heart syndrome; MRI; chest pain; reversible cardiomyopathy; stress cardiomyopathy; takotsubo.

Figure 1

Long axis, four chamber and short axis in STIR (A,B) and IR (C,D,E) sequences of a patient with TC where edema is visualized (arrows) and no LGE. However, a nuclear scan (F) shows hypoperfusion (arrowheads) of the affected area in MR. These findings support the presence of some sort of microcirculatory dysfunction leading to ischemia. Abbreviations: IR, inversion-recovery; TC, takotsubo cardiomyopathy; LGE, late gadolinium enhancement.

Figure 2

Symptomatic (A,B,C) and follow-up (D,E,F) MR scan of a patient with TC. Notice the apical ballooning (arrows) as visualized during systole in the long and short axis, as well as the edema (arrowhead). Follow-up images show complete reversibility of the findings. Abbreviation: TC, takotsubo cardiomyopathy.

Figure 3

Established workflow at our institution. When a patient presents with a confirmed ACS (Chest pain, ECG + and Troponin +) a coronary angiography is performed. Before the angiography and at the patient’s bedside an echocardiography is usually performed (although considered optional) in order to start risk stratifying the patient and coming up with possible differentials. If the angiography is concordant with the clinical and echocardiographic findings an MI is diagnosed and further studying of the patient ceased. If the angiography findings are discordant an MR is performed. In light of the MR findings the patient will be classified as a probable TC, to be confirmed through a three months follow-up MR, or will be classified into another set of diseases that can present as an ACS. Abbreviations: ACS, acute coronary syndromes; MI, myocardial infarction; TC, takotsubo cardiomyopathy.

Figure 4

Typical findings in TC. Cine sequence (A) shows apical ballooning during systole (arrow). STIR sequence in four chamber (B) and short axis (C) planes show wall edema on the same area (arrowheads). Finally, IR sequence in short axis (D) ten minutes after GD injection shows absence of LGE. Abbreviations: TC, takotsubo cardiomyopathy; IR, inversion-recovery; LGE, late gadolinium enhancement.

Figure 5

MR scan of a patient with known cardiac sarcoidosis shows findings compatible with TC (A,B,C,D) and sarcoidosis (E,F). Cine sequences (A,B) show apical ballooning (arrows). STIR and IR sequences (C,D,E,F) show a patchy area of LGE (dotted arrow) with no associated edema (E,F) and an area of edema (arrowheads) with no associated LGE (C,D). Thus, coexistence of two overlapping heart diseases has to be taken into account and looked for when abnormal MR findings are observed. Abbreviations: TC, takotsubo cardiomyopathy; IR, inversion-recovery; LGE, late gadolinium enhancement.

Figure 6

STIR (A,B) and IR (C,D) sequences in a patient with TC show minimal LGE in the apico-medial wall (arrowheads) in concordance to the area of edema (arrows). Abbreviations: TC, takotsubo cardiomyopathy; LGE, late gadolinium enhancement.