International Journal of Cardiology 174 (2014) e36–e37
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
“Double takotsubo”: First description of the sequence of classical followed by inverted type in a young woman Niklas F. Ehl ⁎, Marzena Zurek, Hans Rickli, Micha T. Maeder Division of Cardiology, Kantonsspital St. Gallen, Switzerland
a r t i c l e
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Article history: Received 23 March 2014 Accepted 2 April 2014 Available online 16 April 2014 Keywords: Stress-induced cardiomyopathy Classical as well as inverted type Takotsubo Strain imaging
A 28-year-old woman was referred with chest pain and interstitial pulmonary edema five weeks after giving birth to her third child. She described her life as very exhausting and stressful. Cardiac troponin I was slightly elevated, the initial ECG was inconclusive. Echocardiography showed severely reduced left ventricular ejection fraction (LVEF) with akinesia and severely reduced strain of all apical and midventricular segments, while the basal segments were hyperkinetic (end-systolic still frames of apical four-, two- and three-chamber views as well as longitudinal 2D strain “bull's eye” showing the regional
⁎ Corresponding author at: Division of Cardiology, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland. Tel.: + 41 71 494 10 51l; fax: + 41 71 494 61 42. E-mail address: [email protected] (N.F. Ehl).
http://dx.doi.org/10.1016/j.ijcard.2014.04.064 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
distribution of peak systolic strain in Panel A in the figure; Supplementary material video S1). Coronary computed tomography angiography revealed normal coronary arteries. Cardiac magnetic resonance imaging confirmed the wall motion abnormalities but did not show any late enhancement or evidence of myocardial edema. Clinically, the patient recovered within a few days with standard heart failure treatment Fig. 1. A repeat echocardiogram obtained ten days after the initial presentation revealed significantly improved LVEF; in particular, contraction and strain in the apical and midventricular segments had normalized. However, the basal segments now were hypokinetic and – in addition to a somehow delayed contraction – showed reduced strain (Panel B; Supplementary material video S2). An echocardiogram one month later revealed normal contraction and strain in all segments from base to apex (Panel C; Supplementary material video S3). To the best of our knowledge this is the first reported case of a patient presenting with the sequence of classical followed by inverted type of takotsubo cardiomyopathy within a few days. Assessment of longitudinal 2D strain proved as an excellent method to document the sequence of events. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.04.064.
N.F. Ehl et al. / International Journal of Cardiology 174 (2014) e36–e37
e37
Fig. 1. Panel A: typical takotsubo cardiomyopathy — shown by end-systolic still frames of apical four- (top left), two- (top right) and three-chamber views (bottom left) as well as longitudinal 2D strain “bull's eye” (bottom right) showing the regional distribution of peak systolic strain. Panel B: inverted takotsubo cardiomyopathy — shown by end-systolic still frames of apical four- (top left), two- (top right) and three-chamber views (bottom left) as well as longitudinal 2D strain “bull's eye” (bottom right) showing the regional distribution of peak systolic strain. Panel C: normalization of above shown wall motion abnormalities — shown by end-systolic still frames of apical four- (top left), two- (top right) and three-chamber views (bottom left) as well as longitudinal 2D strain “bull's eye” (bottom right) showing the regional distribution of peak systolic strain.
Contents lists available at ScienceDirect
International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard
Letter to the Editor
“Double takotsubo”: First description of the sequence of classical followed by inverted type in a young woman Niklas F. Ehl ⁎, Marzena Zurek, Hans Rickli, Micha T. Maeder Division of Cardiology, Kantonsspital St. Gallen, Switzerland
a r t i c l e
i n f o
Article history: Received 23 March 2014 Accepted 2 April 2014 Available online 16 April 2014 Keywords: Stress-induced cardiomyopathy Classical as well as inverted type Takotsubo Strain imaging
A 28-year-old woman was referred with chest pain and interstitial pulmonary edema five weeks after giving birth to her third child. She described her life as very exhausting and stressful. Cardiac troponin I was slightly elevated, the initial ECG was inconclusive. Echocardiography showed severely reduced left ventricular ejection fraction (LVEF) with akinesia and severely reduced strain of all apical and midventricular segments, while the basal segments were hyperkinetic (end-systolic still frames of apical four-, two- and three-chamber views as well as longitudinal 2D strain “bull's eye” showing the regional
⁎ Corresponding author at: Division of Cardiology, Kantonsspital St. Gallen, Rorschacherstrasse 95, CH-9007 St. Gallen, Switzerland. Tel.: + 41 71 494 10 51l; fax: + 41 71 494 61 42. E-mail address: [email protected] (N.F. Ehl).
http://dx.doi.org/10.1016/j.ijcard.2014.04.064 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved.
distribution of peak systolic strain in Panel A in the figure; Supplementary material video S1). Coronary computed tomography angiography revealed normal coronary arteries. Cardiac magnetic resonance imaging confirmed the wall motion abnormalities but did not show any late enhancement or evidence of myocardial edema. Clinically, the patient recovered within a few days with standard heart failure treatment Fig. 1. A repeat echocardiogram obtained ten days after the initial presentation revealed significantly improved LVEF; in particular, contraction and strain in the apical and midventricular segments had normalized. However, the basal segments now were hypokinetic and – in addition to a somehow delayed contraction – showed reduced strain (Panel B; Supplementary material video S2). An echocardiogram one month later revealed normal contraction and strain in all segments from base to apex (Panel C; Supplementary material video S3). To the best of our knowledge this is the first reported case of a patient presenting with the sequence of classical followed by inverted type of takotsubo cardiomyopathy within a few days. Assessment of longitudinal 2D strain proved as an excellent method to document the sequence of events. Supplementary data to this article can be found online at http://dx. doi.org/10.1016/j.ijcard.2014.04.064.
N.F. Ehl et al. / International Journal of Cardiology 174 (2014) e36–e37
e37
Fig. 1. Panel A: typical takotsubo cardiomyopathy — shown by end-systolic still frames of apical four- (top left), two- (top right) and three-chamber views (bottom left) as well as longitudinal 2D strain “bull's eye” (bottom right) showing the regional distribution of peak systolic strain. Panel B: inverted takotsubo cardiomyopathy — shown by end-systolic still frames of apical four- (top left), two- (top right) and three-chamber views (bottom left) as well as longitudinal 2D strain “bull's eye” (bottom right) showing the regional distribution of peak systolic strain. Panel C: normalization of above shown wall motion abnormalities — shown by end-systolic still frames of apical four- (top left), two- (top right) and three-chamber views (bottom left) as well as longitudinal 2D strain “bull's eye” (bottom right) showing the regional distribution of peak systolic strain.
