Ultrasound Case of the Month

the case

The patient is a teenage male presenting to the Shock Resuscitation Unit (SRU) after a high speed MVC.  He was the restrained driver and single occupant of a vehicle that struck a pick-up truck head-on at approximately 50 mph.  EMS reported a prolonged extrication due to heavy damage to the patient’s vehicle.  Pre-hospital he was hypotensive and unresponsive with agonal breathing.  EMS placed a supraglottic device and was providing assisted ventilations on arrival. History was otherwise limited as the patient was not responsive. 

The Physical Exam

HR 78 BP 125/69      RR 20      SpO2 100%

The patient is ill-appearing and pale.  A supraglottic device is in place with clear and equal breath sounds auscultated bilaterally.  He has normal pulses throughout.  His GCS is 3T - pupils are 7mm bilaterally and not reactive to light.  His secondary exam is notable for multiple complex orthopedic injuries

A FAST (Focused Assessment with Sonography in Trauma) exam was performed.

And now for the ultrasound images…


+ What do you see on ultrasound?

The subcostal view of the FAST exam showed a dilated and hypokinetic left ventricle (LV). A parasternal long view was then obtained, which confirmed the presence of a dilated LV with severely reduced systolic function. More detailed evaluation suggested the LV was diffusely hypokinetic with preservation of the basal wall motion, consistent with the most common form of Takotsubo Cardiomyopathy (TCM), also known as stress-induced cardiomyopathy.


+Discussion

TCM was first described in Japan in 1990, and the word “Takotsubo” is taken from the Japanese name for an octopus trap, which is shaped similar to the apical-ballooning of the LV seen on TTE or Ventriculography of the most common form of TCM (Figure 1) (1). It is characterized as a transient depression in LV systolic function that often mimics an acute myocardial infarction however with non-obstructive coronaries on angiography (2). The prevalence of the disease varies and is somewhat dependent on the underlying etiology.

Figure 1. classic findings of Takotsubo cardiomyopathy. Image obtained from https://en.wikipedia.org/wiki/Takotsubo_cardiomyopathy.

Figure 1. classic findings of Takotsubo cardiomyopathy. Image obtained from https://en.wikipedia.org/wiki/Takotsubo_cardiomyopathy.

The classic presentation of TCM is an elderly woman experiencing chest pain or dyspnea after a recent emotional or physical trigger. In the International Takotsubo Registry of 1750 patients, 89.9% were women, with a mean age of 66.4 years (2). Identified triggers included physical (36%), emotional (27.7%), combined (7.8%), and none (28.5%). Troponin levels were elevated in 87% of patients. Compared with a matched cohort of occlusive myocardial infarction patients, the rate of ST-segment elevation on ECG was similar, while ST-segment depressions were less common. In a separate registry of patients presenting with NSTEMI and STEMI, the prevalence of TCM was 1-2% based on left heart catheterization (3). Numerous other “stress-response states” have been linked with TCM. In a prospective observational study of 92 MICU patients, admitted for non-cardiac issues and without any significant cardiac history, 28% were found to have LV apical-ballooning consistent with TCM (4). Sepsis was the only predictor of TCM in multivariable analysis. Cases of TCM have been found in patients suffering from neurological insults, including spontaneous subarachnoid hemorrhage and traumatic brain injuries (TBI) (5). Traumatic injuries, both blunt chest trauma as well as blunt trauma not involving the chest wall, have also caused TCM in certain patients (6-8).

To review the more typical presentation of TCM, let us examine another case presentation. A middle aged female with a history of recently diagnosed squamous cell carcinoma of the lung status-post resection two months ago with subsequent frequent hospitalizations presented to the ED due to nausea, vomiting, left-sided chest pain, and difficulty breathing. Her EKG revealed new t-wave inversions in the inferior and lateral leads and her initial troponin was 2.43. Her bedside TTE revealed a diffusely hypokinetic and dilated LV with sparing of the basal wall (Figure 2). She had non-obstructive coronary artery disease on angiography and was diagnosed with TCM.

The actual etiology of TCM is unknown, although various mechanisms have been proposed including catecholamine excess and coronary artery spasm. An excess in catecholamine concentration is the most widely accepted pathogenic model. A physical or emotional stressor often precipitates TCM, and these “fight-or-flight” scenarios are known to induce a subsequent adrenergic surge. It is postulated that this can lead to a catecholamine-induced microvascular spasm or myocardial toxicity, resulting in myocardial stunning (9). Studies have also measured the catecholamines at presentation in TCM patients and found that norepinephrine levels were elevated in 74% of patients.

Diagnosis of TCM is made by the Mayo Clinic diagnostic criteria, all of which need to be present to make the diagnosis:

  • Transient LV systolic dysfunction
  • Absence of obstructive coronary disease or acute plaque rupture on angiography
  • New EKG changes OR modest elevation in cardiac troponin
  • Absence of pheochromocytoma or myocarditis

There are different variants of TCM that may be seen on echocardiography. The most common pattern, seen in our patient, is the apical type, which appears to show apical-ballooning due to the depressed apical and mid-segments with preserved and often hyperdynamic basal wall motion. This represents 81.7% of patients in the International Takotsubo Registry. The mid-ventricular type is the second most common (14.6%) and consists of hypokinetic mid-ventricle with sparing of the apex and basal walls. The basal type (2.2%), also known as the reverse or inverted Takotsubo, demonstrates hypokinesis of the base with sparing of the mid and apical segments. Finally, a very rare (1.5%) focal variant exists which affects an isolated segment of the LV.

As part of the Mayo Criteria for diagnosis of TCM, this is a transient process and over the course of days to weeks patients will recover their myocardial function. Treatment in the interim generally follows usual heart failure management with beta blockers, ace-inhibitors, and diuretics as needed (10). In certain cases, TCM can cause cardiogenic shock, which developed in 10% of patients in the International Takotsubo Registry (2). Treatment in these circumstances may include inotropic agents and vasopressors in addition to mechanical support (eg intra-aortic balloon pump) (11,12).

Brief hospital course: The patient was admitted to the intensive care unit on an epinephrine infusion. A consultative transthoracic echocardiogram was performed, showing an ejection fraction (EF) of approximately 25% with severe diffuse hypokinesis and preservation of the basal wall function. His troponin I peaked at 4.94 and unfortunately succumbed to his other injuries.

+Ultrasound Pearls

Takotsubo is a diagnosis of exclusion, and the echocardiographic appearance can look remarkably similar to a proximal LAD lesion causing ischemic cardiomyopathy. Remember that part of the diagnostic criteria is non-obstructive coronaries on angiography, so these patients need a LHC.

Numerous “stress-response states” have caused TCM beyond the elderly woman suffering from an acute emotional event, so keep this diagnosis on your radar.


AUTHORED BY SHAUN HARTY, MD

PEER REVIEWED BY PATRICK MINGES, MD


REFERENCES

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  2. Templin C, Ghadri JR, Diekmann J et al. Clinical features and outcomes of Takotsubo (Stress) cardiomyopathy. New Eng J Med. 2015;373:929–38. doi: 10.1056/NEJMoa1406761.

  3. Kurowski V, Kaiser A, von Hof K, Killermann DP, Mayer B, Hartmann F et al. Apical and midventricular transient left ventricular dysfunction syndrome (tako-tsubo cardiomyopathy): frequency, mechanisms, and prognosis. Chest. 2007;132(3):809–16.

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  10. Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, Rihal CS. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST‐segment elevation myocardial infarction. Ann Intern Med. 2004;141:858–865.

  11. UpToDate management and prognosis of stress (Takotsubo) cardiomyopathy accessed 10/18/2018

  12. Sharkey SW, Lesser JR, Zenovich AG et al. Acute and Reversible Cardiomyopathy Provoked by Stress in Women From the United States. Circulation. 2005;111:472–9.