Takotsubo syndrome: the need to evaluate the left and right atria, in addition to the left and right ventricles

Abstract

Takotsub o syndrome (TTS) is an acute reversible heart failure condition which morphologically is expressed via imaging modalities [transthoracic echocardiography (TTE) (conventional and strain deformation TTE), contrast ventriculography, or cardiac magnetic resonance imaging (cMRI)], as segmental left ventricular (LV) phenotypes of hypokinesis/akinesis/dyskinesis involving the apical, mid-ventricular, basal (i.e. reverse or inverse), focal, and rarely global LV territories. This pre-occupation with the LV is understandable, considering that morbid symptoms and signs of TTS are ascribed to a compromise of the LV, contrast ventriculography at cardiac catheterization is restricted to the LV, and diagnostic TTE is focused on the LV, with an often cursory reference to the right ventricle (RV), for which a brief statement in TTE reports commonly includes that the ‘RV size and function were normal’, or that the RV could not be adequately evaluated. It is conceivable that if systematic and careful attention, during TTE evaluation was paid to the RV, more patients with TTS will be detected as having RV involvement (RVi), and if conventional TTE had disclosed normal RV findings, resort to strain TTE deformation imaging would have uncovered frequent RVi, of varying severity. This matter is of significance since it has been already established that RVi is encountered in one-fourth to one-third of patients with TTS, and such RVi portends a worse prognosis and a higher rate of major adverse cardiovascular effects. ¹ It has also been rarely observed that there is only RVi in some patients with TTS. There is no doubt that probable RVi is detected more comprehensively by cMRI, than by TTE. ¹ There is literature on the evaluation of left atrium (LA), employing TTE velocity vector imaging, ² and both LA and right atrium (RA) via TTE and cMRI. ^3–5 Recent work focused on the biatrial (i.e. LA and RA) strain and strain rate changes in patients with TTS, employing cMRI feature tracking, documenting impairment of the reservoir, conduit, and booster functions of both LA and RA. ⁴