Late gadolinium enhancement does occur in Tako-tsubo cardiomyopathy — A quantitative cardiac magnetic resonance and speckle tracking strain study

Abstract

BackgroundLate gadolinium enhancement (LGE) on cardiac magnetic resonance imaging (CMR) has been recommended to distinguish Tako-tsubo cardiomyopathy (TTC) from either acute myocardial infarction or myocarditis.Method44 consecutive patients with confirmed Mayo Clinic criteria for TTC underwent CMR imaging at 1.5 Tesla during the acute phase. 10 patients who had CMRI to exclude scar related ventricular tachycardia, and had negative studies, were used as negative controls. LGE was quantitated at two signal intensity thresholds (CircleCVi software) at > 2 and > 5 standard-deviations (SD) above reference myocardium, and compared to biomarkers.FindingsMean door-to-CMR time was 57 hours. 18 patients (41%) had LGE > 2 SD localized to the area of abnormal wall motion, representing 28.9 ± 11.2% LV mass. In 16 of these 18 patients (89%) LGE signal intensity was > 5 SD above normal myocardium, representing 12.1 ± 10% LV mass. LGE signal intensity was significantly greater in TTC than in matched controls (p < 0.05) but lower than in STEMI patients (p < 0.05). Mean troponin was significantly higher in LGE positive patients (2.5 ± 1.8 vs 4.4 ± 6.9, p = 0.001). Mean ejection fraction (EF) by CMR was 45% ± 8.7 in LGE-negative, and 40% ± 7.1 in LGE-positive patients (p = 0.37). Recovery of segmental function was confirmed at follow-up, mean EF was 59% in both groups.ConclusionLGE was present in 41% of cases of TTC, 89% of which had intense enhancement > 5 SD above normal myocardium. Presence of LGE was associated with worse myocardial injury in the acute setting, with no difference in recovery of function.

The Case for Takotsubo Cardiomyopathy (Syndrome) as a Variant of Acute Myocardial Infarction

“…4 Late gadolinium enhancement has been reported in 40% of patients with takotsubo cardiomyopathy (with the use of a threshold of 2 SD above remote myocardium), associated with higher troponin levels. 5 This observation suggests that the degree of myocardial necrosis present in most takotsubo events approaches the resolution of current cardiac magnetic resonance.…”

Advances in Imaging and Heart Failure: Where are we Heading?

“…42 CMR is the primary non-invasive imaging modality for the assessment of suspected myocarditis in clinically stable patients, by evaluating LV function. [43][44][45] In patients with heart failure and possible iron overload, CMR with T2* provides definitive diagnosis. CMR in cardiac amyloidosis typically reveals increased myocardial gadolinium enhancement (global, sub-endocardial or transmural), short T1, rapid blood pool wash-out and suboptimal myocardial nulling.…”

“…123 I-labelled MIBG, as a marker of adrenergic neuron function, could play an important role in the risk stratification of heart failure patients. 46 A major focus has been on the ability of 123 I-MIBG imaging to risk-stratify patients for risk of ventricular arrhythmic sudden cardiac death, and thereby guide the use of an ICD. 46 As cardiac autonomic innervation is more closely related to underlying mechanisms of arrhythmias than LVEF, MIBG imaging should better determine the need for an ICD.…”

“…46 A major focus has been on the ability of 123 I-MIBG imaging to risk-stratify patients for risk of ventricular arrhythmic sudden cardiac death, and thereby guide the use of an ICD. 46 As cardiac autonomic innervation is more closely related to underlying mechanisms of arrhythmias than LVEF, MIBG imaging should better determine the need for an ICD. 46,47 Furthermore, emerging studies highlight the role of coronary flow reserve with stress myocardial perfusion PET as an independent predictor of diastolic dysfunction and adverse effects, especially hospitalisation of heart failure patients with preserved EF.…”

“…46 As cardiac autonomic innervation is more closely related to underlying mechanisms of arrhythmias than LVEF, MIBG imaging should better determine the need for an ICD. 46,47 Furthermore, emerging studies highlight the role of coronary flow reserve with stress myocardial perfusion PET as an independent predictor of diastolic dysfunction and adverse effects, especially hospitalisation of heart failure patients with preserved EF. 48 The presence of both coronary microvascular and diastolic dysfunction was associated with a markedly increased risk of heart failure events.…”