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Review
. 2020 Nov 1;93(1115):20200514.
doi: 10.1259/bjr.20200514. Epub 2020 Aug 14.

Advanced cardiac magnetic resonance imaging in takotsubo cardiomyopathy

Vineeta Ojha  1 , Rishabh Khurana  1 , Kartik P Ganga  1 , Sanjeev Kumar  1
Affiliations
Review

Advanced cardiac magnetic resonance imaging in takotsubo cardiomyopathy

Vineeta Ojha et al. Br J Radiol. .

Abstract

Takotsubo cardiomyopathy (TC) is a reversible condition in which there is transient left ventricular (LV) dysfunction characterised most commonly by basal hyperkinesis and mid-apical LV ballooning and hypokinesia. It is said to be triggered by stress and mimics, such as acute coronary syndrome (ACS) clinically. Diagnosis is usually suspected on echocardiography due to the characteristic contraction pattern in a patient with symptoms and signs of ACS but normal coronary arteries on catheter angiography. Cardiac magnetic resonance (CMR), with its latest advancements, is the diagnostic modality of choice for diagnosis, prognosis and follow-up of patients. The advances in CMR (including T1, T2, ECV mapping and threshold-based late gadolinium enhancement (LGE) measurements have revolutionised the role of CMR in tissue characterisation and prognostication in patients with TC. In this review, we highlight the current role of CMR in management of TC and enumerate the CMR findings in TC as well the current advances in the field of CMR, which could help in prognosticating these patients.

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Figures

Figure 1.
Figure 1.
The diagnostic pathway for Takotsubo cardiomyopathy. Abbreviation: MINOCA: Myocardial infarction with non-obstructive coronary arteries; ACS: Acute coronary syndrome; CTA: CT angiography; FFR: Fractional flow reserve; IVUS: Intravascular ultrasound.
Figure 2.
Figure 2.
Outline of the CMR imaging protocol for Takotsubo cardiomyopathy.
Figure 3.
Figure 3.
Cine CMR 4-chamber view showing typical left ventricular apical ballooning in Takotsubo cardiomyopathy (a: late diastole; b: late systole) (LV: Left ventricle).
Figure 4.
Figure 4.
Cine CMR 2-chamber view showing typical left ventricular apical ballooning in Takotsubo cardiomyopathy (a: late diastole; b: late systole) (LV: Left ventricle).
Figure 5.
Figure 5.
Graphics showing various patterns of contraction in Takotsubo cardiomyopathy: (A) mid-ventricular to apical ballooning (most common pattern); (B) mid-ventricular ballooning; (C) basal ballooning; (D) biventricular involvement: dilatation and ballooning of both the left ventricle (LV) and the right ventricle (RV); (E) focal ballooning (rarest).
Figure 6.
Figure 6.
Longitudinal strain (LS) analysis by feature-tracking CMR at the end-systole in 4-chamber view (a), and 2-chamber view (b) in a patient with the “mid to apical ballooning pattern” of Takotsubo cardiomyopathy. The colour-scale is given at the left side of the images. Blue represents negative LS (representative of normal strain pattern since there is shortening of myocardium in systole, normal strain values are usually more negative than −17%). Red represents positive LS (abnormal strain pattern as myocytes cannot shorten). At end-systole, the yellow-orange-red areas represent the mid-apical left ventricular ballooning suggesting abnormal LS. (Software CVI42, Circle Cardiovascular Imaging Inc., Calgary, Canada).
Figure 7.
Figure 7.
(a) The curve of the global longitudinal strain (GLS) of the left ventricle (LV) against time as assessed by feature-tracking CMR. The peak GLS here is −4.6%, meaning deranged GLS in a patient with Takotsubo cardiomyopathy. (Software CVI42, Circle Cardiovascular Imaging Inc., Calgary, Canada). (b) Bull's eye plots showing segment-wise LV strain values: peak radial strain, peak circumferential strain and peak longitudinal strain. Peak radial strain is red/positive/ normal in basal segments and deranged in mid-apical segments (radial strain is normally positive since the myocardium thickens in systole). Peak circumferential strain is blue/negative/normal in basal segments and abnormal in mid-apical segments (Circumferential strain is normally negative due to circumferential LV contraction in systole). Peak longitudinal strain is deranged in all the segments.(Software CVI42, Circle Cardiovascular Imaging Inc., Calgary, Canada).
Figure 8.
Figure 8.
Myocardial oedema in a patient with Takotsubo cardiomyopathy. T2W inversion recovery sequence in short-axis view (a) show no obvious hyperintense areas on visual estimation. T2 mapping (b) at the same level reveals elevated T2 value (mean: 63.4 ms) suggestive of oedema.
Figure 9.
Figure 9.
(a-h) Short-axis CMR delayed PSIR sequence showing patchy subtle hyperintensities (LGE) involving mid-apical left ventricular segments (a through c), in a patient with Takotsubo cardiomyopathy of “classical pattern”.
Figure 10.
Figure 10.
Short axis CMR LGE image at the apical segment in a 60-year-old female with Takotsubo cardiomyopathy (mid-apical ballooning pattern). The image shows semi-automated quantification of LGE/scar at a threshold of 3 SD above the mean signal intensity of remote myocardium (denoted here with hand-drawn blue ROI). The percentage of scar was 3.3% of the LV myocardium. At 5 SD, the software could not perceive any LGE/scar. (Software CVI42, Circle Cardiovascular Imaging Inc., Calgary, Canada).
Figure 11.
Figure 11.
Elevated native T1 map value (Average native T1 – 1360 ms) in a patient with Takotsubo cardiomyopathy.
Figure 12.
Figure 12.
ECV maps in a patient with Takotsubo cardiomyopathy, generated from pre and post-contrast T1 maps by a post-processing software (CVI42, Circle Cardiovascular Imaging Inc., Calgary, Canada). The colour bar (0 through 60) shows the % of ECV. Normal ECV (usually within 30%) is denoted by green-yellow. Orange to red denotes higher ECV. (a) shows normal (green-yellow) ECV map at basal LV (Average ECV −26%), (b) shows abnormal (red) ECV values at apical LV (Average ECV – 47%).
Figure 13.
Figure 13.
Cine CMR image in a patient with Takotsubo cardiomyopathy shows a sleeve of pericardial effusion (asterisks).
See this image and copyright information in PMC

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