International Journal of Cardiology 184 (2015) 492–493

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Letter to the Editor

Takotsubo cardiomyopathy: Utility of cardiac magnetic resonance to stratify risk for sudden cardiac death Asad Ghafoor, Rajesh Janardhanan ⁎ Sarver Heart Center, Division of Cardiology, University of Arizona, United States

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Article history: Received 23 January 2015 Accepted 1 March 2015 Available online 4 March 2015 Keywords: Takotsubo cardiomyopathy Cardiac magnetic resonance Late gadolinium enhancement Sudden cardiac death

An 80-year-old female presented with sudden onset of retrosternal chest pain. She had no prior history of coronary artery disease (CAD). Her only risk factors for atherosclerosis included her age and a history of hypertension that was controlled with medical therapy. She denied any history of cigarette smoking or alcohol abuse. Upon initial questioning, she revealed that her symptoms started shortly after an argument with her husband. Upon presentation, cardiac exam was unremarkable. Initial EKG showed sinus rhythm with occasional premature ventricular contraction (PVC), but no ischemic ST/T wave changes. Approximately 2 weeks prior to this presentation, she had undergone an exercise stress echocardiogram. The stress echocardiogram showed no resting wall motion abnormalities and no evidence of ischemia during stress. One hour after initial presentation, laboratory markers revealed mild troponin elevation at 0.81 ng/mL, serum Na 132 mmol/L, serum K 3.6 mmol/L and serum Mg 2.1 mmol/L. Approximately 3 h after initial presentation, EKG revealed 0.5 mm ST elevations in leads III and aVF. Another 30 min later, patient had an episode of ventricular fibrillation (VF) that was defibrillated with 200 J delivered externally. Immediately afterwards she was awake and responsive. Amiodarone 150 mg was loaded by bolus fashion, followed by continuous infusion at 1 mg/min. Troponin measurement at this time was 4.61 ng/mL. She was immediately transferred to the cardiac catheterization lab. Coronary angiography

⁎ Corresponding author at: Non-Invasive Cardiac Imaging, Banner - University Medical Center Tucson, Sarver Heart Center, Box 245037, 1501 N. Campbell Avenue, Tucson, Arizona, United States. E-mail address: [email protected] (R. Janardhanan). 0167-5273/Published by Elsevier Ireland Ltd.

revealed no obstructive coronary artery disease. Left ventriculography revealed prominent apical ballooning (Fig. 1). Patient was hemodynamically stable at the end of the procedure. While en-route to ICU, she had another episode of VF. Once again she was successfully defibrillated with 200 J delivered externally. Subsequent EKGs revealed sinus bradycardia with QT prolongation, which led to discontinuation of amiodarone infusion. Approximately 10 h after initial presentation, 2D echocardiography confirmed apical ballooning with hyperkinetic basal segments, but an otherwise preserved left ventricular ejection fraction (LVEF) of 60%. Urine and serum studies for metanephrine, catecholamines and 5-HIAA were obtained. TSH and FT4 levels were also obtained. All levels were reported within normal range. EKG on day 2 showed diffuse deep T wave inversions in all precordial leads. Risk stratification for a future event was done with cardiac magnetic resonance (CMR) imaging on day 2 by evaluating for presence and extent of scar. Late gadolinium enhancement (LGE) was defined as signal intensity (SI) N 5 SD above normal remote myocardium. Based on this parameter, areas of LGE were noted in the entire apex and distal-inferior septum (Fig. 2). Scar burden was quantified at approximately 20% of myocardial segments. Myocardial edema could not be quantified due to suboptimal T2 weighted imaging secondary to patient's inability to breath-hold during CMR. The LVEF was calculated to be 55%. The patient received a single chamber ICD for secondary prevention on day 3. Takotsubo cardiomyopathy has been known to mimic an acute coronary syndrome (ACS) like presentation, representing 2% of ACS cases per year in the United States [1]. This case represented a rare combination of Takotsubo cardiomyopathy, VF arrest upon presentation and evidence of significant LGE on CMR imaging. A review of literature shows that sustained ventricular tachyarrhythmias occur in b5% of Takotsubo cases, and as a mode of presentation in approximately 1% of Takotsubo cardiomyopathy cases [2,3]. Strategies for risk stratification of sudden cardiac death (SCD) have not been identified in this cohort. Less than one third of all patients that receive ICDs based on current guidelines will benefit in terms of SCD prevention [4]. Myocardial scarring detected by cardiac MRI is an independent predictor of adverse outcome in patients being considered for ICD placement, irrespective of LVEF measurements. Scar burden quantified by LGE at N 5% despite LVEF N 30% has been shown to be an independent predictor of high risk for SCD [5]. In the largest study of CMR imaging on Takotsubo patients, LGE was not evident when using N 5 SD of normal SI as the cutoff value for LGE [6]. However LGE has been reported in patients with Takotsubo cardiomyopathy [7–9], especially when using lower cutoff values for SI [6,8,9].

A. Ghafoor, R. Janardhanan / International Journal of Cardiology 184 (2015) 492–493


Strategies for SCD risk stratification in this population do not exist due to a lack of published data and lack of consensus amongst experts. The timing of device implantation is also controversial in Takotsubo cardiomyopathy, which is generally considered to be a potentially reversible condition. We hypothesize that device implantation based on scar burden on CMR can be an effective risk stratification strategy in this population when significant LGE is present. This merits further investigation in larger studies of patients with Takotsubo cardiomyopathy.

Conflict of interest The authors report no relationships that could be construed as a conflict of interest.

Appendix A. Supplementary data Supplementary data to this article can be found online at http://dx.

References Fig. 1. Left ventriculography showing prominent apical ballooning.

Fig. 2. Late gadolinium enhancement involving the entire apex and distal-inferior septum on CMR imaging.

Whether the presence of LGE in Takotsubo cardiomyopathy confers an elevated SCD risk is not yet known. Ventricular fibrillation with Takotsubo cardiomyopathy in the absence of LGE on CMR imaging has been reported [10] and associated with poor prognosis [9]. To our knowledge, a presentation of Takotsubo cardiomyopathy with VF and significant LGE on CMR imaging has not been reported to date.

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Takotsubo cardiomyopathy: Utility of cardiac magnetic resonance to stratify risk for sudden cardiac death.

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