Optical Coherence Tomography Findings in Tako-Tsubo Cardiomyopathy
2012; Lippincott Williams & Wilkins; Volume: 126; Issue: 13 Linguagem: Inglês
10.1161/circulationaha.112.122200
ISSN1524-4539
AutoresFernándo Alfonso, Iván J. Núñez‐Gil, Rosana Hernández,
Tópico(s)Cardiac electrophysiology and arrhythmias
ResumoHomeCirculationVol. 126, No. 13Optical Coherence Tomography Findings in Tako-Tsubo Cardiomyopathy Free AccessBrief ReportPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessBrief ReportPDF/EPUBOptical Coherence Tomography Findings in Tako-Tsubo Cardiomyopathy Fernando Alfonso, MD, Iván J. Núñez-Gil, MD and Rosana Hernández, MD Fernando AlfonsoFernando Alfonso From Interventional Cardiology, Cardiovascular Institute, Clinico San Carlos University Hospital, IdISSC, Madrid, Spain. , Iván J. Núñez-GilIván J. Núñez-Gil From Interventional Cardiology, Cardiovascular Institute, Clinico San Carlos University Hospital, IdISSC, Madrid, Spain. and Rosana HernándezRosana Hernández From Interventional Cardiology, Cardiovascular Institute, Clinico San Carlos University Hospital, IdISSC, Madrid, Spain. Originally published25 Sep 2012https://doi.org/10.1161/CIRCULATIONAHA.112.122200Circulation. 2012;126:1663–1664Tako-Tsubo (TT) cardiomyopathy is a rare clinical entity, initially described in Japan, characterized by a transient apical dyskinesia of unknown origin.1,2 Patients present with signs and symptoms typical of myocardial infarction, but the epicardial coronary arteries are normal and left ventricular wall motion abnormalities spontaneously resolve during follow-up.1–2 Although different etiologies have been proposed to explain the pathophysiology of TT, its cause remains unknown. Here we describe optical coherence tomography findings of a patient presenting with TT.A 63-year-old woman with a history of hypertension was admitted for prolonged chest pain. An ECG showed widespread 1- to 2-mm ST-segment elevation from V2 to V5. An echocardiogram revealed extensive anteroapical akinesia. Urgent coronary angiography using a left radial access revealed normal coronary arteries (completely smooth angiographic appearance) with normal antegrade coronary flow. Left ventricular angiography (Figure 1) disclosed a pattern characteristic of apical ballooning. The wall motion of the anterobasal and posterobasal left ventricular segments was hyperdynamic and left ventricular ejection fraction was 30%. Left ventricular end-diastolic pressure was 25 mm Hg, mitral regurgitation was absent, and no intraventricular gradient could be detected. Frequency domain optical coherence tomography (Dragon Fly, C7-XR, LightLab Imaging, St. Jude Medical, St. Louis, MO) with a nonocclusive technique was used to interrogate both the left anterior and left circumflex coronary arteries. Special care was taken to obtain an exhaustive and completely blood-free examination of the vessel wall using repeated, overlapping imaging sequences to interrogate the longest possible segment of both vessels. Three runs were obtained in the left anterior descending coronary artery (total image length, 9 cm) and 2 runs in the left circumflex coronary artery (total image length, 6 cm). Notably, the vessel walls of both arteries appeared completely normal: wall thickness ranged from 170–340 μm and had the characteristic 3-layered structure of a healthy vessel. Atherosclerotic changes (fibrotic, calcified, lipid pools) were not visualized at any segment. In addition, no images of ruptured or eroded intima were detected. Finally, no trace of residual thrombus (red or white) was disclosed at any location (Figure 2). The patient had a peak creatine phosphokinase level of 181 IU (troponin I, 1.43 ng/mL) and did not develop Q waves. Evolving electrocardiographic changes (anterior negative T waves) progressively normalized. Six days after admission she was discharged with an echocardiogram showing a normal left ventricular function without wall motion abnormalities.Download figureDownload PowerPointFigure 1. Left ventricular angiography (A, diastole; B, systole) showing the characteristic morphological pattern of Tako-Tsubo cardiomyopathy.Download figureDownload PowerPointFigure 2. Optical coherence tomography pull-back depicting sequential images (A–F) (at approximately 1-cm intervals) starting distal in the left anterior descending coronary artery (A) and ending at the most proximal segment of the vessel (F). Notice a completely normal vessel wall along the entire vessel, with a characteristic 3-layered appearance, lack of atherosclerotic changes, and intimal disruptions or residual thrombi. Asterisk indicates wire artifact.Our findings demonstrate that TT cardiomyopathy may occur in patients without any structural abnormality of the epicardial coronary vessels. To our knowledge, this is the first report assessing the value of optical coherence tomography to rule out subtle pathological changes in the coronary vessel wall in TT cardiomyopathy. The characteristic absence of angiographic coronary artery disease in this entity does not exclude the possibility of minor pathologic changes at the coronary vessel wall. Indeed, previous studies using intravascular ultrasound suggested that some patients with TT have angiographically silent atherosclerosis or even ruptured plaques.3,4 However, the unique resolution (15 μm) of this technique provides reassuring—nearly histological—evidence that the TT syndrome also may occur in patients with structurally normal coronary arteries. This suggests that alternative pathophysiologies should be investigated further. Additional optical coherence tomography studies in larger series of patients are required to fully elucidate the underlying pathophysiology of this elusive and challenging clinical condition.DisclosuresNone.FootnotesCorrespondence to Fernando Alfonso, MD, Interventional Cardiology, Cardiovascular Institute, Clínico San Carlos University Hospital, IdISSC, Plaza Cristo Rey, Madrid 28040, Spain. E-mail [email protected]comReferences1. Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, Yoshiyama M, Miyazaki S, Haze K, Ogawa H, Honda T, Hase M, Kai R, Morii I. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol. 2001; 38:11–18.CrossrefMedlineGoogle Scholar2. Sharkey SW, Windenburg DC, Lesser JR, Maron MS, Hauser RG, Lesser JN, Haas TS, Hodges JS, Maron BJ. Natural history and expansive clinical profile of stress (tako-tsubo) cardiomyopathy. J Am Coll Cardiol. 2010; 55:333–341.CrossrefMedlineGoogle Scholar3. Ibañez B, Navarro F, Cordoba M, M-Alberca P, Farre J. Tako-tsubo transient left ventricular apical ballooning: is intravascular ultrasound the key to resolve the enigma? Heart. 2005; 91:102–104.CrossrefMedlineGoogle Scholar4. Haghi D, Hamm K, Heggemann F, Walter T, Suselbeck T, Papavassiliu T, Borggrefe M. Coincidence of coronary artery disease and Tako-Tsubo cardiomyopathy. Herz. 2010; 35:252–256.CrossrefMedlineGoogle Scholar Previous Back to top Next FiguresReferencesRelatedDetailsCited By Alfonso F and Virmani R (2019) Intracoronary imaging for the diagnosis of the underlying substrate and clinical management of acute coronary syndromes: from evidence to expert consensus … and back!, EuroIntervention, 10.4244/EIJV15I5A71, 15:5, (392-395), Online publication date: 1-Aug-2019. 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Jiménez Brítez G, Sabaté M, Robles C, García-Granja P, Amat-Santos I and Brugaletta S (2018) Análisis morfológico y funcional de la arteria descendente anterior de pacientes con síndrome de tako-tsubo, Revista Española de Cardiología, 10.1016/j.recesp.2017.08.008, 71:11, (986-988), Online publication date: 1-Nov-2018. Cecchi E, Parodi G, Fatucchi S, Angelotti P, Giglioli C, Gori A, Bandinelli B, Bellandi B, Sticchi E, Romagnuolo I, Mannini L, Antoniucci D and Abbate R (2016) Prevalence of thrombophilic disorders in takotsubo patients: the (ThROmbophylia in TAkotsubo cardiomyopathy) TROTA study, Clinical Research in Cardiology, 10.1007/s00392-016-0977-x, 105:9, (717-726), Online publication date: 1-Sep-2016. Núñez-Gil I, Mejía-Rentería H and Martínez-Losas P (2016) Practical update of Takotsubo syndrome, Medicina Clínica (English Edition), 10.1016/j.medcle.2016.05.018, 146:5, (212-217), Online publication date: 1-Mar-2016. 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Bossone E and Erbel R (2013) The "Takotsubo Syndrome": From Legend to Science, Heart Failure Clinics, 10.1016/j.hfc.2013.01.001, 9:2, (xiii-xv), Online publication date: 1-Apr-2013. Fineschi M, D'Ascenzi F, Sirbu V, Mondillo S and Pierli C (2013) Reply, Echocardiography, 10.1111/echo.12195, 30:6, (738-738), Online publication date: 1-Jul-2013. September 25, 2012Vol 126, Issue 13 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.112.122200PMID: 23008472 Originally publishedSeptember 25, 2012 PDF download Advertisement SubjectsAcute Coronary SyndromesImaging
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