Extracellular Volume Analysis Using Computed Tomography Is Useful for Follow-up of Takotsubo Syndrome

A 65-year-old woman was admitted to hospital complaining of chest pain. Her electrocardiogram revealed negative T waves in precordial leads (Figure A), and acute coronary syndrome was suspected. No significant stenosis was detected on her emergency invasive coronary angiography (Figure B,C). Left ventriculography showed ballooning of the apical left ventricular myocardium (LVM), suggesting coronary vasospasm of the left anterior descending artery or Takotsubo syndrome (TTS; Figure D). Two days after admission, cardiac computed tomography (CT) was performed because of the repetitive chest symptom. No significant coronary artery stenosis was detected, but extracellular volume (ECV) was measured (Ziostation 2, Ziosoft, Inc., Tokyo, Japan), and it was elevated on apical LVM on CT (Figure E,F, arrows). The ECV is the size of the extracellular space, which reflects myocardial edema or fibrosis. Four days after the CT, cardiac magnetic resonance imaging (MRI) showed a high signal intensity in the apical LVM on the T₂-weighted image (Figure G, arrows), which indicates myocardial edema. However, late gadolinium enhancement on LVM, which indicates myocardial fibrosis, was not detected (Figure H). An acetylcholine provocation test was performed on Day 11, and coronary artery spasm was not induced. Therefore, we diagnosed the patient with TTS. Six months later, follow-up CT showed decreased ECV on the apical LVM (Figure I,J).

Figure.

(A) Electrocardiogram revealing negative T waves in precordial leads. (B,C) No significant stenosis was seen on coronary angiography. (D) Left ventriculography showed ballooning of the apical left ventricular myocardium (LVM). (E,F) Extracellular volume (ECV) was measured (Ziostation 2, Ziosoft, Inc., Tokyo, Japan) and was elevated on the apical LVM on computed tomography (CT). (G) Cardiac magnetic resonance imaging showed a high signal intensity in the apical LVM on the T₂-weighted image, indicating myocardial edema. (H) Late gadolinium enhancement on LVM, which indicates myocardial fibrosis, was not detected. (I,J) Follow-up CT 6 months later showed decreased ECV on the apical LVM.

Cardiac MRI is useful for detecting transient myocardial edema in the acute phase of TTS.¹ As far as we know, this is the first report revealing the reversibility of CT-ECV elevation caused by myocardial edema in TTS.

Sources of Funding

This work was supported by JSPS KAKENHI Grant no. JP23K11891.

Disclosure

Y.K. is a member of Circulation Journal’s Editorial Team. The remaining authors have no conflicts of interest to declare.

Reference

• 1.   Kato K, Daimon M, Sano M, Matsuno K, Sakai Y, Ishibashi I, et al. Dynamic trend of myocardial edema in Takotsubo syndrome: A serial cardiac magnetic resonance study. J Clin Med 2022; 11: 987.