An Extensive Review on Imaging Diagnosis Methods in Takotsubo Syndrome

Abstract

Takotsubo Syndrome (TS) is an acute, reversible cardiac dysfunction, with complex, not entirely understood pathophysiology and heterogeneous clinical picture. Imaging methods each have a crucial role in the diagnosis, in-hospital management, short term and long term follow up. Coronary angiography needs to be performed, especially in the setting of a suspected acute coronary syndrome, in order to rule out coronary artery disease. Echocardiography plays a central role both in the acute and the chronic phase. It is the first imaging investigation performed in patients with TS, valuable to diagnose systolic dysfunction, the wall motion pattern and early complications. Cardiac magnetic resonance tissue characterization provides an essential role in the differential diagnosis of TS with other non-ischemic causes of systolic dysfunction. This review focuses on the imaging methods and the important part they play in the complex management of the disease.

Keywords: acute coronary syndrome; cardiac magnetic resonance; coronary angiography; echocardiography.

Fig. 1.

Coronary angiography in a 53 year-old female patient with Takotsubo Syndrome. Non-obstructive epicardial coronary arteries - images (A) and (B). Ventriculography showing apical akinesia and basal hyperkinesia - images (C) and (D).

Fig. 2.

Transthoracic echocardiography images apical four-chambers views of a 73 year-old female patient with Takotsubo Syndrome. Apical akinesia in the acute phase (A and B) and normalized wall motion and ejection fraction at 1 month follow-up (C and D).

Fig. 3.

Transthoracic echocardiography images apical four-chambers views of a 73 year-old female patient with Takotsubo Syndrome showing the evolution of diastolic function. E wave velocity progressed from 40 cm/s in the acute phase to 70 cm/s at one month follow-up, the E/A ratio from 0.5 to 0.8 (A and B). Lateral e’ velocity increased from 4 cm/s to 8 cm/s and E/e’ ratio from 10 to 8.7 (C and D). 2D, two dimensional; PW, pulsed wave doppler; TDI, tissue doppler imaging.

Fig. 4.

Speckle tracking echocardiography showing the improvement in global longitudinal strain and time to peak longitudinal strain from the acute phase (A) to 1 month follow-up (B). GLS, global longitudinal strain.

Fig. 5.

Cardiac Magnetic Resonance Imaging of a 78 years old female patient in the acute phase of Takotsubo Syndrome. Myocardial edema can be observed in the apical regions of the left ventricle in T2 weighted images (A and B) and the lack of late gadolinium enhancement in C and D.

Fig. 6.

Imagistic Diagnostic Flowchart of Takotsubo Syndrome (Modified after Ghadri et al. 2018 [3]). CAD, coronary artery disease; CMR, cardiac magnetic resonance; ECG, electrocardiogram; MINOCA, Myocardial infarction with non-obstructive coronary arteries; STE, ST segment elevation; TTE, transthoracic echocardiography; WMA, wall motion abnormalities; CCTA, coronary computed tomography angiography; TS, Takotsubo syndrome; CV, cardiovascular.