Slowly Resolving Global Myocardial Inflammation/Oedema in Tako-Tsubo Cardiomyopathy: Evidence From T2-Weighted Cardiac MRI

Study Questions:

What is the distribution and time-course of myocardial edema associated with Tako-Tsubo cardiomyopathy (TTC)?

Methods:

The study investigators performed T2-weighted cardiac magnetic resonance (CMR) imaging in 32 patients with acute TTC, and evaluated the distribution and severity of myocardial edema as measured by T2-weighted signal density. The diagnosis of acute TTC was based on clinical criteria, which included abnormal ST/T waves, sustained elevation of troponin values, characteristic wall motion abnormalities, and exclusion of obstructive coronary artery disease in the territory of the wall motion abnormality. A follow-up CMR was performed on 24 patients at a median of 105 days following the index study. CMR was additionally acquired in 10 age-matched female controls to identify normal ranges of T2-weighted signal intensity.

Results:

Mean age was 67 years, and 97% were female. Individuals with acute TTC had a significant gradient in T2-weighted signal intensity that increased from the base to the apex (p < 0.001), and even basal segments had significantly higher signal intensity as compared to normal controls (p < 0.001). In the subset of 24 individuals with follow-up CMR, there was resolution of the signal intensity gradient between the apex and base on follow-up imaging (p > 0.05), and a significant decrease in signal intensity was observed (p < 0.001). Nevertheless, global signal intensity remained elevated as compared to normal controls (p < 0.02).

Conclusions:

TTC is associated with globally increased myocardial edema as measured by T2-weighted signal intensity on CMR, with increased myocardial edema observed in apical segments. In the subset with follow-up CMR, there was a decrease in myocardial edema, although it remained significantly elevated as compared to controls.

Perspective:

While TTC is typically regarded as a transient process that predominantly involves apical segments, this study reports globally increased myocardial edema in the acute setting, with greater edema observed towards the apex. These data suggest a more global process that is not limited to segments with visible wall motion abnormalities. Further, while myocardial edema decreased on follow-up imaging at 3 months, global measures of myocardial edema remained elevated compared to controls, suggesting an incomplete resolution of the acute event. This study provides intriguing data on the natural history of acute TTC. Future research is needed to assess the clinical significance of myocardial edema associated with TTC, and to determine whether these findings resolve with additional time.

Clinical Topics: Heart Failure and Cardiomyopathies, Noninvasive Imaging, Atherosclerotic Disease (CAD/PAD), Magnetic Resonance Imaging

Keywords: Inflammation, Coronary Artery Disease, Myocardial Infarction, Follow-Up Studies, Ventricular Dysfunction, Takotsubo Cardiomyopathy, Cardiology, Myocarditis, Edema, Magnetic Resonance Spectroscopy, Magnetic Resonance Imaging, Troponin


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