Tako tsubo cardiomyopathy(Octopus trap) is an enigmatic cardiomyopathy, characterized by marked apical asynergy in the absence of significant coronary disease.
A 77-year-old Caucasian female with history of bovine aortic valve replacement 5 years ago, recently presented to the Emergency Room(ER) with severe typical anginal pain, following the news of her brother’s death. At the time of presentation to the ER, she was hemodynamically stable and her physical exam was unremarkable except for 1+ bilateral ankle edema. Her significant laboratory work up included a positive troponin T of 0.83 ng/ml (normal <0.1 ng/ml); EKG showed first degree AV block, left axis deviation and 0.5mm-1mm ST elevations in V2 to V4; an urgent transthoracic echocardiogram done at the peripheral hospital showed extensive anteroapical akinesis. An emergency coronary angiography at our hospital revealed only a minimal atherosclerotic disease. Left ventriculography demonstrated significantly depressed left ventricular(LV) function with extensive akinesis of the apex, anterior apical, mid anterior, inferoapical and mid inferior segments with an EF estimated at 30%. Basal segments were vigrously contracting. Given the extent of the wall motion abnormality to the lack of significant coronary artery disease, a diagnosis of Tako-tsubo was entertained. Echocardiogram performed the next day demonstrated a severe dilatation and akinesis of the apical and mid segments. Perfusion echocardiogram using Optison showed absence of perfusion in the apex and distal septum while perfusion was preserved in the mid septum and mid lateral wall(graph 1). Repeat Perfusion study 72 hours later showed improved perfusion in all walls except the apex (graph 2). The LV function had only marginally improved in the interim.
Tako tsubo cardiomyopathy has been characterized by reversible apical ballooning of the left ventricule(1). It is common in elderly females. Emotional or physical stress has been recognized as a triggering factor(1). Transient ST-T segment changes is seen on EKG with only minimal evidence of epicardial coronary artery stenosis. It was first described in Japanese patients (123), but has recently been recognized in Caucasians and other too(456). The exact mechanism is unknown but microvascular dysfunction is suspected. Simultaneous multivessel spasm is also considered as possible etiology. Evidence of decreased blood flow in the apical segments has been shown by nuclear and PET perfusion studies. Perfusion echocardiogram is a new technique and literature review shows perfusion echocardiogram been performed in this condition in only one prior patient. We performed perfusion echocardiogram in this rare but increasingly recognized condition.
Perfusion echocardiogram gives us insight about the possibility of microvascular dysfunction as the cause of this transient apical stunning in Tako - tsubo cardiomyopathy.
S.P. Upadya, None.