Right ventricular involvement in Takotsubo cardiomyopathy

Introduction

Takotsubo syndrome (TS) is characterized by a transient apical ballooning of the left ventricle, reversible ST-T-segment abnormalities and mildly elevated troponin without coronary artery stenosis, mimicking myocardial infarction (MI). Originally described as a disturbance of the left ventricle, recently an involvement of the apex of the right ventricle (RV) has been recognized affecting approximately one-quarter of cases.

Methods

TS was diagnosed in 10 patients (nine female, one male; mean age 67 years) who displayed typical signs of acute myocardial ischemia, showed typical ECG changes and slightly elevated troponin I (0.8 ng/ml; n ± 3.5 ng/ml; normal < 0.3 ng/ml). Echocardiography was obtained on admission in all patients. TS was presumed by identification of the typical LV apical ballooning configuration (echo positive). In 10 patients left heart catheterization was then performed immediately.

Results

All patients displayed LV apical ballooning on LV angiography without coronary artery lesions. Nine patients were echo positive (90%; sensitivity 91%, specificity 100%); in the one echo-negative patient the LV angiogram showed only a very small apical ballooning area. In all of the nine patients classified as echo positive, involvement of the RV apex was identified as well. Additional hypokinesia of the middle part of the RV was seen in two patients; however, the basal RV wall segments were never compromised. One patient showed dynamic LV outflow tract obstruction.

Conclusion

RV involvement was a common feature in TS, involving 90% of patients. In all cases, the apical portion of the RV was compromised, the basal segments were never affected. In most patients the typical wall motion disturbance was readily seen on transthoracic echocardiogram. RV involvement was identified in all echo-positive patients. Probably, identification of RV apical ballooning may aid in differentiating TS from MI.