A case report of recurrent takotsubo cardiomyopathy including the rare 'inverted' form

Abstract

Background: Takotsubo cardiomyopathy (TC) is a disease that causes transient left ventricular (LV) dysfunction in multiple vascular territories in the absence of coronary artery disease. Takotsubo cardiomyopathy is typically associated with dilation and dyskinesia of the apical and mid-LV segments induced by acute emotional and/or physical stress. Here, we present a case of recurrent TC including one episode of inverted TC, which is a rare form where dyskinesia occurs in the basal segments with sparing of the apical segments.

Case summary: A 53-year-old female patient with a background history of chronic stress and anxiety was admitted with three episodes of recurrent TC over 4 years. The first episode in 2017 was triggered by an acute stressful event, but no major triggers were identified for the subsequent episodes. Although the first and third episodes displayed the signs of classical TC, the second episode was an inverted TC. Full cardiac function was restored after each episode. She now takes prognostic heart failure medications long term and mental health teams are trying to support her emotional wellbeing.

Discussion: This patient displayed a rare disease course involving three recurrent episodes of TC, including one instance of its inverted form. Although psychiatric conditions and emotional stress are acknowledged as risk factors for TC, further research is needed to assess whether mental health treatment following TC can prevent disease recurrence.

Keywords: Cardiac MRI; Case report; Echocardiography; Inverted takotsubo cardiomyopathy; Recurrent takotsubo cardiomyopathy; Takotsubo.

Figure 1

Cardiac magnetic resonance T2 mapping and native T1 mapping in March 2021. Cardiac magnetic resonance T2 mapping (T2-prepared steady-state free precession) basal short-axis view (A) showed significantly increased T2 values in the basal segments (up to 65 ms in the basal inferolateral segments and 59 ms in the basal anteroseptum) compared with the mid-segments (which were normal, having all T2 values <45 ms). Corresponding native T1 mapping (MOdified Look-Locker Inversion Recovery) basal short-axis view (B) showed T1 values significantly increased in the basal segments (up to 1470 ms in the basal inferior) compared with the mid-segments (which were normal, having all native T1 values <1300 ms). All cardiac magnetic resonance scans performed for this case used a 3 T scanner (MAGNETOM Skyra, Siemens Healthcare) and images were analysed with reference to expert consensus reported in the Journal of Cardiovascular Magnetic Resonance.

Figure 2

Late gadolinium enhancement during cardiac magnetic resonance in March 2021. Late gadolinium enhancement imaging two-chamber view (acquired 10 min after intravenous injection of 0.2 mmol/kg gadolinium-based contrast agent using a phase-sensitive inversion-recovery gradient-echo sequence) showed faint mid-wall type of hyperenhancement in the basal inferior wall segment. Cardiac magnetic resonance T2 mapping (T2-prepared steady-state free precession) basal short-axis view (A) showed significantly increased T2 values in the basal segments (up to 65 ms in the basal inferolateral segments and 59 ms in the basal anteroseptum) compared with the mid-segments (which were normal, having all T2 values <45 ms). Corresponding native T1 mapping (MOdified Look-Locker Inversion Recovery) basal short-axis view (B) showed T1 values significantly increased in the basal segments (up to 1470 ms in the basal inferior) compared with the mid-segments (which were normal, having all native T1 values <1300 ms). All cardiac magnetic resonance scans performed for this case used a 3 T scanner (MAGNETOM Skyra, Siemens Healthcare) and images were analysed with reference to expert consensus reported in the Journal of Cardiovascular Magnetic Resonance.