Takotsubo cardiomyopathy - atypical location

Case contributed by Dr Yune Kwong

Presentation

Suspicion of a ventricular aneurysm and contained rupture on transthoracic echocardiography.

Patient Data

Age: 55 years old
Gender: Female

No evidence of ventricular rupture, but the cine images show the mid anterior wall to be dyskinetic, bulging outwards on systole. On STIR, the affected myocardial segment is hyperintense consistent with edema. No thrombus on early gadolinium images, and no myocardial hyperenhancement on late gadolinium images. Small pericardial effusion present. The calculated left ventricular ejection fraction was in the low-normal range (not shown).

Case Discussion

Repeat transthoracic echocardiography 4 weeks later showed resolution of the dyskinetic anterior wall and pericardial effusion, with improvement in ejection fraction. The appearances, combined with a spontaneous delayed resolution, are consistent with Takotsubo (stress-induced) cardiomyopathy. The location is atypical as the apical segments are usually involved in this condition. However, three other distinct patterns are recognized namely biventricular, mid-ventricular (as in this case), and basal.

The majority of patients with Takotsubo cardiomyopathy are post-menopausal women, and a stressful trigger can be identified in about 70%. On MRI, myocardial edema and a lack of ischemia or fibrosis (as evidenced by lack of enhancement at late gadolinium imaging) are expected findings.

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