Takotsubo Syndrome: An International Expert Consensus Report on Practical Challenges and Specific Conditions (Part-1: Diagnostic and Therapeutic Challenges)

Figures

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  Figure 1. Typical shape of “octopus trap” at end-systole on invasive ventriculogram in a patient with apico-midventricular TTS. TTS, Takotsubo syndrome.

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  Figure 2. Various morphological patterns of takotsubo syndrome (TTS) on invasive left ventriculogram in the right anterior oblique view during diastole (D) and systole (S): (1) mid-apical pattern; (2) mid-ventricular pattern; (3) basal or mid-basal pattern (also termed inverted TTS); (4) focal pattern (focal anterior); (5) mid-apical pattern with apical tip-sparing namely the nipple sign (white arrow).

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  Figure 3. Challenging conditions in TTS diagnosis. *Including acute neurological conditions, sepsis, etc. that might potentially mask cardiovascular manifestations of TTS.24,25; ***Ischemic or post-ischemic myocardial stunning that might mimic a true TTS episode.28,35; TTS, Takotsubo syndrome; WMA, wall motion abnormality.

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  Figure 4. The InterTAK diagnostic score. *Excluding lead aVR; TTS, Takotsubo syndrome.

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  Figure 5. Invasive left ventriculogram and cardiac magnetic resonance imaging (CMR) in a middle-aged woman presenting with chest pain after a stressful situation. Coronary angiogram on admission revealed normal left and right coronary arteries. Invasive left ventriculogram demonstrated typical mid-apical takotsubo syndrome (TTS) with an apical tip-sparing pattern (A, B). Cardiac MRI 3 days after admission demonstrated mild improvement in left ventricular function particularly in the apical region in cine images (C, D). Native T1 mapping demonstrated significant increases in T1 values in the mid-apical regions particularly in the septal and anterior segments [(E, F), white arrows]. Extracellular volume (ECV) mapping also demonstrated significant increases in ECV values representing myocardial edema in the corresponding areas [(G, H), white arrows]. Images of late gadolinium enhancement were consistent with an increased transmural signal intensity (but no infarction changes) in the mid-apical region particularly the septal segment [(I, J), white arrows]. Consequently, this demonstrates “myocarditis-like” changes in the mid-apical (septal and anterior segments) in a typical case of TTS.

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  Figure 6. A proposed clinical algorithm for TTS diagnosis in the presence of diagnostic challenges. ACS, acute coronary syndrome; NSTEMI, non-ST segment elevation myocardial infarction; STEMI, ST segment elevation myocardial infarction; MINOCA, myocardial infarction with non-obstructive coronary arteries; TTS, Takotsubo syndrome; PE, pulmonary embolism; MRI, magnetic resonance imaging; V/P, ventilation perfusion; CAG, coronary angiogram; LV, left ventricle; PCI, percutaneous coronary intervention; WMA, wall motion abnormality; CCTA, coronary computed tomography angiography; CAD, coronary artery disease; ECG, electrocardiogram. *: ACS presentation denotes classical symptoms of ACS (chest pain, dyspnea, etc.) and significant increases in serum levels of myocardial enzymes (including troponins) with or without ischemic ECG changes. Decision making for the initial diagnostic modality (invasive CAG vs CCTA) is generally based on the presence of ST segment elevation, high-risk clinical features and the likelihood of TTS (InterTAK score ≤ 70 vs. > 70).6,13,17,23 **: High risk features include persistent chest pain, hemodynamic instability and malignant arrhythmogenesis. ***: Invasive CAG in this…

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  Figure 7. A summary of the therapeutic challenges in patients with uncomplicated TTS. TTS, Takotsubo syndrome.