Diagnosing Takotsubo cardiomyopathy with the help of CMR

Takotsubo, or "broken heart syndrome," is a fascinating disease. Often triggered by an acutely stressful event (such as death of a loved one), it can be hard to differentiate from myocardial infarction. In this video, you'll learn how to diagnose and assess Takotsubo with the help of cardiac MRI.

Targeted towards internists, cardiologists, and radiologists in training, this course teaches you everything you need to know about cardiac MRI (CMR) from a clinical perspective. You'll learn when to order it and how to assess common conditions, including myocardial ischemia, infarction and viability, common cardiomyopathies, valvular stenosis, regurgitation, and common congenital defects.

[00:00:00] In this lecture, we're going to learn how to assess takotsubo cardiomyopathy using CMR. Takotsubo cardiomyopathy is a condition in which there is acute left ventricular dysfunction and this is characterized by apical ballooning. Takotsubo cardiomyopathy is triggered by an acutely stressful event such as the sudden loss of a loved one

[00:00:30] and it is primarily seen in postmenopausal women. Clinically, the presentation is similar to an acute coronary syndrome with chest pain, dynamic ECG changes including ST segments and T waves and an elevated troponin level. But this all occurs in the absence of significant coronary disease on angiography. So, what is the underlying pathology in this condition?

[00:01:00] Well, there is now considerable evidence to indicate that enhanced sympathetic activity plays a key role in the pathogenesis of takotsubo cardiomyopathy. One of the other key features, of this condition, is patients usually go on to make a very good recovery. Serious complications are very uncommon and in most cases, there is full resolution of the left ventricular abnormalities

[00:01:30] within a very short period of time. So, what can CMR offer us diagnostically in the assessment of this condition? Well, here's a cine-CMR image taken in the four-chamber view. We have the left ventricle, left atrium and mitral valve, right ventricle, right atrium, and tricuspid valve. And what we see in this patient with takotsubo cardiomyopathy is ballooning and virtual

[00:02:00] akinesia of the left ventricular apex and this is a very characteristic appearance in a patient with this condition. Here's a two-chamber cine-CMR image showing the left ventricle, mitral valve, left atrium. And again, we can see a degree of ballooning and marked regional wall motion abnormality, of the apex, in this patient with

[00:02:30] takotsubo cardiomyopathy. So, CMR can show us the morphology of the left ventricle, the regional wall motion abnormalities, and allow us to quantify left ventricular function. However, we do need an invasive coronary angiogram to assess the coronary artery anatomy. And this is the left coronary artery in a patient with takotsubo cardiomyopathy and we can see that the coronary arteries are entirely normal. The left anterior descending and circumflex

[00:03:00] coronary arteries showing no evidence of any significant disease. Another characteristic CMR feature is the absence of any late gadolinium enhancement. So, unlike an apical myocardial infarction, where we'd expect to see subendocardial late enhancement in takotsubo cardiomyopathy despite the regional wall motion abnormalities, we don't see any evidence of late gadolinium enhancement on delayed imaging.

[00:03:30] However, if we undertake T2 weighted imaging in the patient during an acute presentation and in the majority of cases, we will see evidence of myocardial edema in the regions where systolic function is abnormal. So, in summary, the key CMR findings in takotsubo cardiomyopathy includes severe left ventricular dysfunction, in a non-coronary distribution,

[00:04:00] typically of the left ventricular apex. If we undertake myocardial edema imaging, we may see evidence of myocardial edema in affected regions. And there is an absence of late gadolinium enhancement, which rules out myocardial infarction. If we perform a follow-up CMR study, after a few weeks, we would expect to see complete or at least near complete resolution of the left

[00:04:30] ventricular abnormalities, on the follow-up study. If you'd like to read more about the CMR findings in takotsubo cardiomyopathy, take a look at this paper in JAMA published in 2011. I hope you found that interesting. Let's check our knowledge with some multiple choice questions. Oh, and don't forget to watch the explanatory videos.