Takotsubo-like transient left ventricular dysfunction or Takotsubo cardiomyopathy was first described in Japan in 1990. Also known as apical ballooning. Named after the Japanese octopus trap – aka Takotsubo (tako – octopus, tsubo – trap).

Characterised by apical ballooning and hyperkinesis of the basal segments.

Classically presents with chest pain and dyspnoea following a period of emotional or physical stress (e.g. sepsis). May mimic acute myocardial infarction and must be initially investigated as such given the presenting symptoms:

  • Sudden onset chest pain & dyspnoea.
  • ECG changes – ST elevation followed by TWI.
  • Apical extensive wall motion abnormalities – often extends beyond single territory.
  • Modest elevation in biomarkers (often less than expected given ECG & RWMAS).

Demographics:

  • More common in East Asian ethnicity followed by caucasian.
  • 90% female.

Exact mechanism has not been elicited but suspected due to catecholamine induced myocardial injury. Noradrenaline was elevated in >70% of patients in one study.

Another mechanism may be related to vasospasm given evidence suggesting reduced coronary flow velocity reserve in these patients.

Coronary microvascular dysfunction probably occurs but evidence is unclear

Prognosis is usually good – most make complete recovery.

Spontaneous resolution of ECG and echo features usually within 3 months. May resolve within 3 days.

Fatal complications including cardiogenic shock, CCF, apical thrombus, arrhythmias and myocardial rupture can occur, risk factors:

  • Persistent ST elevation
  • Female gender
  • Older age
  • Higher systolic/diastolic blood pressure
  • Lower LV ejection fraction.

Management on intensive care may be challenging and the use of catecholamine based cardiovascular support may be problematic given the pathophysiology.

May consider the use of mechanical support e.g. IABP for severe cases.

Echo features:

  • ‘Lightbulb’ shaped left ventricle with apical ballooning.
  • Basal hyperkinesis.
  • Decreased ejection fraction.
  • Dynamic outflow tract obstruction.
  • Dynamic mitral regurgitation.
  • Occasionally ‘reverse Takotsubo’ with lateral or posterior segment involvement and apical hyperkinesis can occur.
  • Right ventricular involvement may occur in >30%

Neurogenic myocardial stunning occurs following an acute neurological event e.g. SAH.

Findings are effectively identical to Takotsubo and may have a similar mechanism (catecholamine surge).

Typically resolves within 3-14 days.