Cardiovascular Imaging in Stress Cardiomyopathy (Takotsubo Syndrome)

Abstract

Stress cardiomyopathy (Takotsubo syndrome) is a reversible syndrome stemming from myocardial injury leading to systolic dysfunction and is usually noted in the setting of a stressful event, be it an emotional or physical trigger. While the exact pathophysiology behind stress cardiomyopathy is yet unknown, there is ample evidence suggesting that neurocardiogenic mechanisms may play an important role. Although historically stress cardiomyopathy was generally thought to be a relatively benign condition, there is growing recognition of the cardiovascular complications associated with it despite its reversibility. Our review aims to shed light onto key cardiovascular imaging modalities used to diagnose stress cardiomyopathy while highlighting the role that imaging plays in assessing disease severity, identifying complications, dictating treatment approaches, and in short-term and long-term prognosis.

Keywords: CMR (cardiovascular magnetic resonance); cardiomyopathy; echocardiography; imaging; stress cardiomyopathy.

Figure 1

Echocardiographic images of a person with stress cardiomyopathy with left ventricular outflow track obstruction (LVOT) and systolic anterior motion (SAM) of the mitral valve. The apical-4-chamber view in diastole (A) and systole (B) and 2-chamber view in diastole (C) and systole (D) showing classic apical ballooning with akinesis and hyperdynamic basal segments. (E,F) Illustrate SAM and turbulence across the LVOT indicative of LVOT obstruction.

Figure 2

A comparison of vertical long axis CMR cine sequence images on diagnosis and at 3-month follow-up showing a recovery of wall motion abnormalities. The four sets of images display four different variants associated with stress CM. The pink asterisk denotes a pericardial effusion. Yellow arrows indicate apical akinesis while the black arrows indicate RV apical akinesis in the biventricular ballooning variant. Figure adapted from Figure 2 on Clinical Characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy by Eitel et al. (41).

Figure 3

T2-weighted sequences demonstrating variability in signal intensity based on the affected myocardial regions. The color coding resembles varying signal intensity ratios between myocardium and skeletal tissue with blue indicating a ratio ≥ 1.9 (indicating edema) while yellow/green indicates a ratio <1.9, indicative of normal myocardium. These images illustrate predominant myocardial edema in the mid-ventricular and apical segments. Adapted from Clinical Characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy by Eitel et al. (41).

Figure 4

Summary of common in-hospital complications associated with stress CM.

Figure 5

Cine CMR horizontal long-axis view illustrating the systolic “jet” seen in LVOT (white arrow) with concurrent systolic anterior motion of the mitral leaflets (green arrow) and functional mitral regurgitation (red arrow). Adapted from Figure 6 in Plácido et al. (39).