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Year : 2012  |  Volume : 11  |  Issue : 1  |  Page : 35-38

Tako-Tsubo Syndrome: Atypical Nuclear Medicine Findings

1 Department of Nuclear Cardiology, Cardiology Institute, Havana, Cuba
2 Department of Echocardiography, Cardiology Institute, Havana, Cuba
3 Department of Cardiology Care Unit, Cardiology Institute, Havana, Cuba

Date of Web Publication19-Jul-2012

Correspondence Address:
Lázaro O Cabrera Rodríguez
Institute of Cardiology, 17 No. 702, Vedado, CP 10400, La Habana
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DOI: 10.4103/1450-1147.98747

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The Tako-Tsubo syndrome is a reversible form of an acute stress-related cardiomyopathy that was reported during the last decade. It typically presents with a constellation of symptoms, electrocardiographic changes, and elevated cardiac enzyme levels consistent with an acute coronary syndrome. However, when the patient undergoes cardiac angiography, left ventricular apical ballooning finding is seen, but no significant coronary artery stenosis. This balloon-like morphology, being the hallmark of this entity, can be detected by imaging. We present a case report of a patient who was admitted to our hospital and met all the diagnostic criteria of the Tako-Tsubo syndrome. Myocardial perfusion imaging (MPI) showed an anteroapical perfusion defect at rest, moderated systolic dysfunction, and intraventricular asynchrony all assessed by gated-SPECT phase analysis. Two months later, all MPI findings returned to normal parameters.

Keywords: Broken heart syndrome, left ventricular apical ballooning, left ventricle dysfunction, Tako-Tsubo cardiomyopathy

How to cite this article:
Cabrera Rodríguez LO, Fernández RG, Quirós Luis JJ, González AP. Tako-Tsubo Syndrome: Atypical Nuclear Medicine Findings. World J Nucl Med 2012;11:35-8

How to cite this URL:
Cabrera Rodríguez LO, Fernández RG, Quirós Luis JJ, González AP. Tako-Tsubo Syndrome: Atypical Nuclear Medicine Findings. World J Nucl Med [serial online] 2012 [cited 2021 Dec 6];11:35-8. Available from: http://www.wjnm.org/text.asp?2012/11/1/35/98747

   Introduction Top

In 1990, Sato et al. [1] described in Japan a new entity with symptoms similar to the acute coronary syndrome. There are similarities in clinical manifestation, electrocardiogram changes, and biomarkers levels. The Tako-Tsubo syndrome received its name from of the similarity between the shape of the left ventricle in systole and the form of the Japanese octopus trap with a narrow neck and wide base [Figure 1] Other names are "stress-induced cardiomyopathy," "heart break syndrome" and "transient ventricular ballooning syndrome". The typical feature is apical ballooning with compensatory hyperkinetic basal segments. This cardiomyopathy represents 1-2% of patients with acute coronary syndrome. It is frequently found in females most commonly postmenopausal; men are affected in less than 10% of cases.
Figure 1: The Japanese octopus trap

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The pathophysiology has been uncertain up to now, although several theories have been discussed, for example: coronary vasospasm, myocarditis and coronary microcirculatory disturbances. Nevertheless the most accepted is an increase in the sympathetic activity because a close relationship has been noted between physical and/or emotional stress precipitating the acute event. To make the diagnosis a coronary angiography must show normal arteries without any stenosis or obstruction. [2],[3],[4],[5],[6] Complications such as cardiogenic shock and heart failure are unusual. [2] Recurrences and death during 2 years of follow-up are very low (less than 2%). [2] Left ventricular function improves in the majority of patients within 1-3 weeks. [4]

   Case Report Top

We report a case of a 46-year-old black woman with the following risk factors: tobacco, high blood pressure (HBP) and family history of coronary artery disease. She was admitted in our Emergency Care Unit (ECU) suffering from sharp chest pain irradiating to her neck and left arm, associated with a brief loss of consciousness and vegetative manifestations. The physical examination was normal. Electrocardiogram (ECG) on admission at less than 1 hour of the onset showed sinusal rhythm, heart rate 100/min, ST segment elevation of 2 mm in V2-V3 and 1 mm in DII, DIII and aVF with inverted T-waves deep and symmetric in V4-V6 and QT interval within normal limits [Figure 2]a. The cardiac biomarkers of heart damage (creatine kinase CK and its isoenzyme CK-MB) were only very slightly elevated in serial measures. Echocardiography revealed a reduction of the left ventricular ejection fraction (LVEF), akinesis of the apical and distal anterior wall with hypercontractility of the basal wall producing the apical ballooning configuration of the LV in systole, typical of this disorder [Figure 3]a-b. The patient underwent emergency cardiac catheterization, which disclosed no significant epicardial coronary artery stenosis [Figure 4].
Figure 2: A 12-lead electrocardiogram (ECG) (a) shows ST-segment elevation and deep T-wave inversions in the V2-V3 and DII, DIII and aVF too in the acute onset. (b) Two months later

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Figure 3: Echocardiography images (Two-chamber long axis) (a-b) Acute onset (a) End-diastole (b) End-systole (c) Two months later

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Figure 4: Coronary angiography (a) Left coronary (b) Right coronary. There is no epicardial coronary stenosis

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Two days after the onset, myocardial perfusion imaging (MPI) with Tc 99 MIBI was performed. Perfusion abnormalities in the left ventricular apex, lateral and anterior walls were documented [Figure 5]a-c. Thickening and contractility were reduced in these segments [Figure 6]a-c.
Figure 5: Tc99 MIBI-SPECT images. Early images (a, c) show decreased myocardial perfusion in distal anterior and lateral wall, and apex. (b, d) after complete recovery

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Figure 6: Bull-eye and thickening images. (a-c) Acute once. (b-d) Two months later

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The analysis of ventricular synchronism was done with gated-SPECT phase analysis using the Emory Cardiac Toolbox. There was an increase in peak phase degree (225), phase SD degree (49.1), and in the phase histogram bandwidth degree (150) [Figure 7]a. Intraventricular asynchrony assessed by gated-SPECT phase analysis was an unexpected finding.
Figure 7: Gated-SPECT. Synchronism, (a) Acute onset. (b) Two months later

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During the patient΄s evolution no other complications appeared. All of the ECG abnormalities returned to the baseline in 7 days [Figure 2]b there was a total recovery in global and regional left ventricular function, evaluated by echocardiography [Figure 3]c. Perfusion defects and synchronism also disappeared in the same period, assessed by nuclear medicine. [Figure 5]b, d and [Figure 7]b.

   Discussion Top

The first case of Tako-Tsubo syndrome was reported in 2001, [2] when its diagnostic criteria were established. It is important to point out that though there are prevailing incidences in elderly females, it is unusual before the menopause. [2],[3],[4],[5],[6] This was not our case. Several series in white populations of Europe, the United States and other countries have been reported, which demonstrate that this disease is not limited to specific ethnic groups or geographic zones. [5],[6],[8] The first case in Latin America was published in 2001; [9] three years later the first case in Cuba was reported, which was also a black woman. [10]

Thoracic pain and acute cardiac failure are frequent forms of presentation [7] ; but syncope, as the first manifestation, has been reported in a few cases. [2],[5] The ST elevation in left precordial leads in ECG is a typical finding. Negative, symmetric and deep T waves, associated with the QTc interval's prolongation, are usually signs found after the second day of the onset of the symptoms. [4],[5] In our case, the ST segment elevation in DII, DIII and aVF and T wave inversion in multiple derivations were found from the beginning of the symptoms [Figure 2]. This ECG pattern has been rarely described in the series of patients reported in the literature.

MPI was performed within 2 days of admission Tc 99 MIBI uptake was decreased in more than one coronary vascular bed. The perfusion defects involved the apex and segments of the anterior and lateral walls. The regional wall motion and the systolic thickening in these segments were affected, showing an important area of akinesia. The ejection fraction at rest was moderately diminished (39%).

Tc uptake by myocytes is via a metabolism-dependent process located in the mitochondria and any mitochondria damage reduces the uptake, even when this damage could be reversible. Different authors consider that any metabolic and/or structural defects can cause scintigraphic abnormalities rather than perfusion changes due to coronary disease. [11]

It has been suggested that autonomic imbalance is related to the development of this condition. The catecholamine-associated myocardial toxicity is the most attractive theory due to elevated catecholamine levels that have been reported in patients with Tako-Tsubo cardiomyopathy. [12],[13],[14],[15],[16] The contraction band necrosis (which is characteristic of catecholamine-induced myocyte injury) found upon histological investigation [17] supports this "sympathoexcitation" hypothesis.

The analysis of ventricular synchronism by gated-SPECT phase analysis showed an intraventricular asynchrony, which might reflect the wall-motion abnormalities or perhaps left ventricular conduction system damage mainly in Purkinje fibers caused by catecholamine-related toxicity. 123 Iodine-metaiodobenzylguanidine ( 123 I-MIBG) uptake in cardiac sympathetic nerves is decreased in patients with stress cardiomyopathy, early images showed decreased myocardial uptake in the distal anterior wall, apex, and inferior wall of the left ventricle, suggesting cardiac sympathetic nerve affectation. [18]

A follow-up SPECT study was obtained 2 months after the onset of symptoms, and perfusion and function abnormalities returned to normal parameters.

The diagnostic criteria for this entity were found in spite of the atypical findings described before. But is very interesting this ventricular dyssynchronism, related to the contractility abnormalities, damage on Purkinje fibers very sensible to oxygen deprive or perhaps the effect of the decrease in sympathetic innervations could be the cause of this asynchronism detected.

   References Top

1.Sato H, Tateishi H, Uchida T. Takotsubo-type cardiomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M, editors. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Tokyo: Kagakuhyouronsya Co; 1990. p. 56 -64.  Back to cited text no. 1
2.Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. Angina Pectoris-Myocardial Infarction Investigations in Japan. J Am Coll Cardiol 2001;38:11-8.  Back to cited text no. 2
3.Prasad A, Lerman A, Rihal CS. Apical ballooning syndrome (Tako- Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 2008;155:408-17.  Back to cited text no. 3
4.Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118:397-409.  Back to cited text no. 4
5.Gianni M, Dentali F, Grandi AM, Sumner G, Hiralal R, Lonn E. Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review. Eur Heart J 2006;27:1523-9.  Back to cited text no. 5
6.Núñez-Gil IJ, Fernández-Ortiz A, Luaces Méndez M, García-Rubira JC, Alonso J, Vivas Balcones D, et al. Apical transient dyskinesia (TakoTsubo cardiomyopathy): A five-year clinical experience in Caucasians. Eur Heart J 2008;29(abstract supplement):53.  Back to cited text no. 6
7.Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, et al. Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 2005;111:472-79.   Back to cited text no. 7
8.Gaspar J, Gómez RA. Síndrome Tako-Tsubo (Discinesia antero-apical transitoria): Primer caso descrito en América Latina y revisión de la literatura. Arch Inst Cardiol Mex 2004;74:205-14.  Back to cited text no. 8
9.Céspedes JC, Pérez J, Almeida J, Álvarez O, Valdés M, Méndez TC. Transient apical dyskinesia syndrome: A case report. Rev cubana med. 2007;46;146-9:278-82.  Back to cited text no. 9
10.Yoshida T, Hibino T, Kako N, Murai S, Oguri M, Kato K, et al. A pathophysiologic study of tako-tsubo cardiomyopathy with F-18 fluorodeoxyglucose positron emission tomography. Eur Heart J 2007;28:2598-604.  Back to cited text no. 10
11.Osherov A, Matetzky S, Beinart R, Hod H. Transient left ventricular Apical Ballooning (Tako-tsubo): The syndrome that mimics Myocardial Infarction. IMAJ 2004;6:550-2.  Back to cited text no. 11
12.Takizawa M, Kobayakawa N, Uozumi H, Yonemura S, Kodama T, Fukusima K, et al. A case of transient left ventricular ballooning with pheochromocytoma, supporting pathogenetic role of catecholamines in stress-induced cardiomyopathy or Takotsubo cardiomyopathy. Int Cardiol 2007;114:e15-e7.  Back to cited text no. 12
13.Abraham J, Mudd JO, Kapur N, Klein K, Champion HC, Wittstein IS. Stress cardiomyopathy after intravenous administration of catecholamines and beta-receptor agonists. J Am Coll Cardiol 2009;53:1320-5.  Back to cited text no. 13
14.Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Sasaka K. Reversible left ventricular dysfunction: "takotsubo" cardiomyopathy related to catecholamine cardiotoxicity. J Electrocardiol 2002;35:351-6.  Back to cited text no. 14
15.Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Koike H, Sasaka K. The clinical features of takotsubo cardiomyopathy. QJM 003;96:563-73.  Back to cited text no. 15
16.Nef HM, Mollmann H, Kostin S, Troidl C, Voss S, Weber M, et al. Tako-Tsubo cardiomyopathy: intraindividual structural analysis in the acute phase and after functional recovery. Eur Heart J 2007;28:2456-64.  Back to cited text no. 16
17.Wendt DJ, Martins JB. Autonomic neural regulation of intact Purkinje system of dogs. Am J Physiol 1990;258(5 Pt 2):H1420-6.  Back to cited text no. 17
18.Akashi YJ, Nakazawa K, Sakakibara M, Miyake F, Musha H, Sasaka K. 123I-MIBG Myocardial scintigraphy in patients with "Takotsubo" cardiomyopathy. J Nucl Med 2004;45:1121-7.  Back to cited text no. 18


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7]


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