Myocardial edema in Takotsubo syndrome mimicking apical hypertrophic cardiomyopathy: An insight into diagnosis by cardiovascular magnetic resonance

Abstract

Myocardial edema is one of the characteristic features in the pathogenesis of Takotsubo syndrome. We report a middle aged man who presented with typical clinical and echocardiographic features of apical variant of Takotsubo syndrome. However, a cardiovascular magnetic resonance study performed 10 days after presentation did not show any apical 'ballooning' but revealed features of an apical hypertrophic cardiomyopathy on cine images. Tissue characterization with T2 weighted images proved severe edema as the cause of significantly increased apical wall thickness. A follow-up cardiovascular magnetic resonance study was performed 5 months later which showed that edema, wall thickening and the appearance of apical hypertrophic cardiomyopathy all resolved, confirming Takotsubo syndrome as the cause of the initial appearance. As the affected myocardium most commonly involves the apical segments, an edema induced increase in apical wall thickness may lead to appearances of an apical hypertrophic cardiomyopathy rather than apical ballooning in the acute to subacute phase of Takotsubo syndrome. May, 2015Dear Editor, We would like to submit for your consideration the manuscript entitled "Takotsubo syndrome with severe myocardial edema mimicking apical hypertrophic cardiomyopathy" as a case report for the Heart & Lung Journal.The case presentation and images are on a novel observation of significantly increased left ventricular (LV) apical wall thickness mimicking apical hypertrophic cardiomyopathy in the course of Takotsubo cardiomyopathy. The localised apical LV "hypertrophy" was demonstrated to be due to marked myocardial edema and resolved in the follow-up study. Such markedly increased apical wall thickness and the resulting LV morphology was not well defined in the course of Takotsubo cardiomyopathy before and may cause significant challenges in the diagnosis and acute management of these cases.I declare that the manuscript containing original material is submitted solely to the Heart & Lung Journal and has not been published or being considered for publication elsewhere. Response to reviewer`s comments:Once again we would like to thank to the reviewer very much for his/her suggestions on improving the manuscript. We have revised the manuscript accordingly 1-We have added the suggested table 2-We have amended the references as suggested (we are grateful for the sympathy of the reviewer that it might be a mundane task to re-arrange the references and we are happy to say that thankfully in this case it did not require a change in the order of the references ) Myocardial edema is one of the characteristic features in the pathogenesis of Takotsubo syndrome. We report a middle aged man who presented with typical clinical and echocardiographic features of apical variant of Takotsubo syndrome. However, a cardiovascular magnetic resonance study performed 10 days after presentation did not show any apical 'ballooning' but revealed features of an apical hypertrophic cardiomyopathy on cine images. Tissue characterizat...

An Endomyocardial Biopsy of the Left Ventricle in an Anorexia Nervosa Patient with Sinus Bradycardia and Left Ventricular Systolic Dysfunction

“…Sachdeva et al showed that an experimental model of Takotsubo cardiomyopathy presents persistent foci of necrosis and fibrosis [4]. Izgi et al reported myocardial edema as one of the characteristic features in the pathogenesis of Takotsubo syndrome [5]. Although the patient in our case study showed signs of Takotsubo cardiomyopathy, the endomyocardial biopsy of the LV did not show necrosis and the cardiac MRI did not demonstrate myocardial edema like in Takotsubo cardiomyopathy.…”

Stress Cardiomyopathy in a Patient with Hypertrophic Cardiomyopathy: Case Presentation and Review of the Literature

“…As previously mentioned, during the acute phase of SCM it is challenging to differentiate the two entities, especially the apical variant of HCM, since in those cases the disease process may be entirely masked by apical thinning or aneurysm caused by the SCM (Roy et al, 2014). The clinical scenario is further confounded in that there have been reports of a recently detected phenomenon of apparent left ventricular apical hypertrophy seen during the subacute and chronic phases of a resolving SCM, in patients without apical HCM (Izgi et al, 2015). In these circumstances the apical hypertrophy is due to transient myocardial edema, which can be detected utilizing cardiovascular magnetic resonance imaging (Izgi et al, 2015).…”

Transient Myocardial Thickening in Cats Associated with Heart Failure

“…In humans, catecholamines may cause toxic myocarditis in cases of phaeocromocytoma 45,51 or stress-induced (Takotsubo) cardiomyopathy due to an exaggerated sympathetic stimulation. 52 Takotsubo cardiomyopathy is a transient left ventricular dysfunction most frequently characterized by an apical "ballooning" phenotype in people, 27,52,53 but myocardial edema mimicking HCM has also been described in Takotsubo cases, and differentiation from true HCM requires advanced cross-sectional imaging. [20][21][22][23]27,54 TMT could then potentially be caused by an emotional or physical stress associated with the reported antecedent events.…”

“…Transient myocardial thickening (TMT) mimicking HCM has been described in some forms of acute/fulminant myocarditis in humans and in atypical cases of stress‐induced (Takotsubo) cardiomyopathy . In both situations, the increased LVWT is associated with myocardial edema …”

“…[20][21][22][23] In both situations, the increased LVWT is associated with myocardial edema. 7,20,[22][23][24][25][26][27] The aims of this study were to identify case details of cats with TMT and CHF from multiple veterinary cardiologists and describe their clinical and echocardiographic characteristics. Additionally, the clinical and echocardiographic features of cats with TMT were compared with a control population of cats with HCM and CHF, to identify characteristics at presentation that might distinguish cats with TMT from HCM.…”