Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Figures

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  Figure 1. Patient with takotsubo syndrome (TTS) and concomitant significant coronary artery disease. Caudal (a) and cranial (b) angiographic views of the left coronary artery. Left cranial view (c) of the right coronary artery. Note the significant stenosis in the circumflex artery (arrow, a) and in the right coronary artery (arrow, c). Typical apical ballooning pattern of TTS at left ventriculography (d and e). (Reprinted with permission from Parodi et al. [18])

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  Figure 2. Left ventriculography of a patient with takotsubo syndrome and typical apical ballooning pattern. Note the presence of the ‘apical nipple’ sign, a small area just at the apex with preserved contractility (arrow heads)

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  Figure 3. Left ventriculography of a patient with takotsubo syndrome and midventricular ballooning pattern. Note the left ventricular apex in end-systole resembling hawk’s beak appearance (arrow heads)

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  Figure 4. Left ventriculography in the right anterior oblique projection demonstrates four different morphological patterns of takotsubo syndrome (TTS): apical, midventricular, basal, and focal type. (Modified and reprinted with permission from Templin et al. [7])

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  Figure 5. Two-dimensional transthoracic echocardiography, apical long-axis views, in patients with mitral regurgitation (MR) due to systolic anterior motion (SAM) of the mitral valve. (A) Severe MR at initial presentation. (B) SAM of the mitral valve at initial presentation. (C) Only mild MR was found at follow-up. (D) SAM of the mitral valve was not found at follow-up. (Modified from Izumo et al. [55])

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  Figure 6. Two-dimensional transthoracic echocardiography, apical four-chamber views, in patients with functional mitral regurgitation (MR). (A) Moderate to severe MR at initial presentation. (B) Mitral valve tethering at initial presentation. (C) Only mild MR was found at follow-up. (D) Mitral valve tethering was not found at follow-up. (Modified from Izumo et al. [55])

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  Figure 7. Longitudinal strain in a patient with typical type of takotsubo syndrome demonstrating left ventricular strain acquisition from standard apical view. Apical ballooning and a base to apex circular gradient of strain are appreciated by the bull’s eye plot, which recovers to normal at follow-up

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  Figure 8. Impaired left ventricular (LV) twist by speckle tracking. In the acute phase, LV twist is significantly impaired mainly due to impaired apical function

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  Figure 9. Visualization of coronary flow in acute myocardial infarction (AMI) and takotsubo syndrome (TTS). Cases 1–3 indicate coronary flow pattern in AMI. Systolic-dominant flow pattern with reduced diastolic flow velocity in Case 1, to-and-from pattern in Case 2, and absence of coronary flow in Case 3, all indicate severe stenosis/occlusion of the left anterior descending artery (LAD). In Case 4, antegrade diastolic coronary flow with reduced deceleration time, typical of TTS in the acute phase. LA, left atrium; LV, left ventricle. (Modified and reprinted with permission from Watanabe [84])

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  Figure 10. Opacification of wall motion abnormalities by contrast echocardiography. Left and right panels show apical four-chamber views with and without contrast agent in a case of takotsubo syndrome. Contrast echocardiography helps opacification of wall motion abnormalities, especially in patients with poor echo images. LA, left atrium; LV, left ventricle; RV, right ventricle

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  Figure 11. Simultaneous three-dimensional modelling of cardiac chambers. Latest echo machines enable automated 3D quantification of chamber volumes and ejection fractions of the four cardiac chambers. 3D quantification has been reported to have higher accuracy and reproducibility than two-dimensional echocardiography. LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle

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  Figure 12. 3D assessment of wall motion abnormality. In addition to quantification of volumes, 3D echocardiography is useful for visual confirmation of patterns of wall motion abnormality. The left and right panels indicate an end-diastolic and end-systolic phase, which clearly depicts apical ballooning with basal hyperkinetic motion