Alkadhi, Hatem

Karlo, Christoph

Luescher, Thomas

Marincek, Borut

Scheffel, Hans

Stolzmann, Paul

Trigo-Trindade, Pedro

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LETTER TO THE EDITORTako-Tsubo Phenomenon: Dual-Source Computed Tomographyand Conventional Coronary AngiographyHans Scheffel Æ Paul Stolzmann Æ Christoph Karlo Æ Pedro Trigo-Trindade ÆBorut Marincek Æ Thomas F. Luescher Æ Hatem AlkadhiReceived: 15 June 2007 / Accepted: 27 June 2007 / Published online: 4 August 2007 Springer Science+Business Media, LLC 2007A 75-year-old woman was admitted to our emergencydepartment with severe chest pain and mild dyspnea thatstarted soon after a marital quarrel with her husband. Her12-lead electrocardiogaphy (ECG) demonstrated an STelevation in the precordial leads, and the plasma troponin Tlevel was elevated to 0.29 ng/mL. An acute myocardialinfarction with ST elevation was assumed, and the patientwas admitted for an emergency catheter coronary angiog-raphy. Her coronary arteries were normal, but leftventriculography demonstrated a severe systolic dysfunc-tion involving the mid and apical myocardial segments,showing apical ballooning (Supplemental Data Movie I).Thus, the diagnosis of tako-tsubo phenomenon was made.The ejection fraction was decreased to 40%. Because of ahistory of pulmonary embolism, the patient was referredfor chest computed tomography (CT) to rule out a recurrentpulmonary embolism. Contrast-enhanced, retrospectivelyECG-gated dual-source CT excluded pulmonary embolismand similarly demonstrated systolic dysfunction with apicalballooning (Supplemenal Data Movie II). After 2 days, thepatient’s symptoms ceased and echocardiography showednormalized left ventricular systolic function.Tako-tsubo phenomenon is characterized by transientleft ventricular systolic dysfunction of unknown etiology.Initially described in Japan [1] and named after an octopus-trapping pot with a round bottom and a narrow neck, it hasalso been recognized more and more in Western countries[2, 3]. It predominantly occurs in postmenopausal womenand frequently after emotional stress. Importantly, such apsychological stressful trigger is not observed in all indi-viduals, and its absence does not exclude the diagnosis. Afew cases have been reported in younger women and males[4]. Rarely, patients present with syncope or an out-of-hospital cardiac arrest. Symptoms clinically mimic acutemyocardial infarction, with the majority of patients pre-senting with chest pain, dyspnea, and mild ST-segmentelevation in precordial leads followed by T-wave inversioninvolving most leads [2]. Plasma troponin T levels areeither normal or only slightly increased and thus contrastthe extent of systolic dysfunction in the acute phase.Patients are usually hemodynamically stable, but clinicalfindings of mild to moderate congestive heart failurecommonly coexist. In a minority of patients, hypotensionmay occur from reduced stroke volume and occasionallyfrom dynamic left ventricular outflow tract obstruction.Cardiogenic shock may be a rare complication. Patientswith tako-tsubo phenomenon generally have a good prog-nosis in the absence of significant underlying comorbidity.The systolic dysfunction and the regional wall-motionabnormalities are transient and full recovery usually occursin most cases without specific therapy [2, 3].The initial imaging for patients with tako-tsubo phe-nomenon is usually performed with catheter coronaryangiography because of the clinical suspicion of acutemyocardial infarction. The left ventriculogram showscharacteristic regional wall-motion abnormalities involvingthe mid and apical segments (Fig. 1). There is sparing ofthe basal systolic function, and the wall-motion abnor-mality extends beyond the distribution of any one singlecoronary artery. Apical sparing variants have also beendescribed [5]. Echocardiography and magnetic resonanceH. Scheffel  P. Stolzmann  C. Karlo  B. Marincek H. Alkadhi (&)Institute of Diagnostic Radiology, University Hospital Zurich,Raemistrasse 100, 8091 Zurich, Switzerlande-mail: hatem.alkadhi@usz.chP. Trigo-Trindade  T. F. LuescherCardiovascular Center, University Hospital Zurich, Zurich,Switzerland123Cardiovasc Intervent Radiol (2008) 31:226–227DOI 10.1007/s00270-007-9140-4imaging have been shown to be excellent both for diag-nosis and for monitoring restitution of left ventricularfunction. CT usually does not represent the first-lineimaging modality for this disease but, similarly, allows thedetection of regional wall-motion abnormalities indicatingapical ballooning, as shown in this case. Due to theincreasing use of CT for emergency evaluation of patientswith acute chest pain, recognition of this rare entity maybecome important, particularly in patients with equivocalclinical and laboratory findings.References1. Dote K, Sato H, Tateishi H, et al. (1991) [Myocardial stunning dueto simultaneous multivessel coronary spasms: a review of 5 cases].J Cardiol 21(2):203–2142. Prasad A (2007) Apical ballooning syndrome: an importantdifferential diagnosis of acute myocardial infarction. Circulation115(5):e56–e593. Stollberger C, Finsterer J, Schneider B (2006) Transient leftventricular dysfunction (tako-tsubo phenomenon): findings andpotential pathophysiological mechanisms. Can J Cardiol22(12):1063–10684. Bybee KA, Kara T, Prasad A, et al. (2004) Systematic review:transient left ventricular apical ballooning: a syndrome that mimicsST-segment elevation myocardial infarction. Ann Intern Med141(11):858–8655. Hurst RT, Askew JW, Reuss CS, et al. (2006) Transientmidventricular ballooning syndrome: a new variant. J Am CollCardiol 48(3):579–583Fig. 1 Catheter angiography ofthe left ventricle (A, B).Ventriculogram of the diastolic(A) and systolic (B) phase in30 right anterior obliqueprojection. Systolic phaserevealed dysfunction of the leftventricular myocardium withhypercontractility of the basalparts (arrows) and reducedmyocardial wall motion of themid to apical regions leading toapical ballooning during systole(arrowheads). Dual-sourcecomputed tomography of theleft ventricular myocardium (C,D). Thick maximum intensityprojections of the diastolic (C)and systolic (D) phase of thecardiac cycle in 30 rightanterior oblique planeresembling the leftventriculogram indemonstrating apical ballooningduring systole (arrowheads)accompanied byhypercontractility of the basalmyocardium (arrows)Letter to the Editor 227123

Tako-Tsubo Phenomenon: Dual-Source Computed Tomography and Conventional Coronary Angiography

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Tako-Tsubo Phenomenon: Dual-Source Computed Tomography and Conventional Coronary Angiography

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