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Cardiac magnetic resonance for assessment of cardiac involvement in Takotsubo syndrome: Do we still need contrast administration?

https://doi.org/10.1016/j.ijcard.2020.03.039Get rights and content

Highlights

  • Non-contrast mapping technique allows non-invasive quantification of acute myocardial injury in Takotsubo cardiomyopathy.

  • Native T1 mapping could diagnose persistent inflammation in TC.

  • Segments with wall motion abnormalities are more involved by the acute process than normokinetic segments.

Abstract

Background

This study evaluated the ability of T1 and T2 mapping cardiovascular magnetic resonance to assess myocardial involvement in Takotsubo syndrome (TTS). We hypothesized that non-contrast mapping techniques can be accurate and sufficient.

Methods

We prospectively analysed 30 patients with TTS and 34 controls. CMR was performed a mean 5 days after the onset of symptoms and after a mean 3 month follow-up.

Results

On admission, compared to controls, TTS patients had significantly higher global T2 values (59 ± 8 ms vs 51 ± 4 ms, p < 0.001), native T1 (1053 ± 75 ms vs 960 ± 61 ms, p < 0.001) and extracellular volume (ECV) fraction (29% ± 5 vs 23% ±3, p < 0.001). The sensitivity and specificity for T2 (cut off: 56 ms) were 62% and 97% respectively; for native T1: (cut off 1011 ms) were 72% and 91% respectively; and for ECV (cut off: 27%) were 72% and 97% respectively. Combining T2 and native T1 provided the best sensitivity (91.7%) with a good specificity (88.2%). No patients had late gadolinium enhancement.

Segmental analysis showed that T2, native T1 and ECV values were significantly higher in regions with wall motion abnormalities (WMA) compared to normokinetic segments (62 ± 9 ms vs 55 ± 5 ms, p < 0.001; 1060 ± 65 ms vs 1025 ± 56 ms, p = 0.02; and 34% ± 5 vs 29% ± 1, p = 0.02). At follow up, native T1 and ECV values did not normalized.

Conclusion

In TTS patients, a non-contrast mapping technique provides a high diagnostic accuracy allowing identification of acute and persistent myocardial injury. Segmental analysis showed that myocardial injury is preferably detected in segments with WMA.

Introduction

Takotsubo syndrome (TTS) is a transient myocardial dysfunction in the absence of significant coronary disease, often triggered by emotional or physical stress [1].

Although the pathogenesis is not completely understood, myocardial edema with the absence of fibrosis have been previously described as markers for reversible myocardial injury using cardiovascular magnetic resonance (CMR) with T2-weighted images and late gadolinium enhancement (LGE) sequences [2]. More recent techniques, overcoming limitations of T2 weighted sequences, such as parametric techniques (native and post-contrast T1 mapping and T2 mapping) allow non-invasive detection of interstitial edema and extracellular matrix abnormalities, a direct result of myocardial injury and one of the characteristic findings in stress-induced cardiomyopathy [3]. However, contrast administration is required to calculate extracellular volume (ECV) fraction from T1 mapping data which can be a limitation in old patients with renal impairment and with concerns about possible gadolinium accumulation deposits in the brain. Moreover, CMR data using T1 and T2 mapping in TTS are still scare with small studies [[4], [5], [6]].

The aim of the study was to assess the diagnostic use of native T1 and T2 mapping for the identification of cardiac involvement in a homogenous population of 30 patients referred with TTS.

Section snippets

Methods

The local institutional committee approved this prospective and single center study of patients with clinical TTS who gave written informed consent. In addition, 34 local controls (age 54 ± 19 years) were included to determine the reference values of T1 T2 mapping and ECV at mid-level.

CMR study was carried out on a 1.5 T system (Avanto, Siemens medical solution) using previously described acquisition parameters [7]. CMR was performed a mean 5 days after the onset of symptoms and after a mean

Results

A total of 30 patients were included, median age was 73 years, with a majority of female (86.7%). In the acute phase, mean LV ejection fraction was 48% with CMR, with an apical form associated with a mid-ventricular involvement in the majority of patients (70%). Wall motion abnormalities (WMA): hypokinesia or akinesia were present in the 4 segments (anterior, septal, inferior and lateral) at the apical level and in the 6 segments (anterior, anteroseptal, inferoseptal, inferior, anterolateral

Discussion

Using technical advances, T1 and T2 mapping in a prospective study with a homogeneous population of mid and apical TTS, we have demonstrated that T2 and native T1 mapping have the ability to detect acute myocardial injury with a high diagnostic accuracy without need of contrast administration.

T2 mapping appears to be more specific (94% in our study) for acute inflammation compared to native T1 mapping. Combining T2 and native T1 augments the sensitivity (91.7%) for inflammation and edema.

CRediT authorship contribution statement

Emmanuelle Vermes: Investigation, Supervision, Writing - original draft, Writing - review & editing. Najete Berradja: Investigation, Methodology, Formal analysis. Ines Saab: Project administration, Formal analysis. Thibaud Genet: Resources. Philippe Bertrand: Formal analysis. Julien Pucheux: Writing - review & editing. Laurent Brunereau: Writing - review & editing.

Declaration of competing interest

The authors have nothing to disclose.

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    Moreover, CMR allow to differentiate TTS from myocarditis which shows typical “patchy” sup-epicardial or mid-ventricular LGE, with “non-epicardial” coronary artery distribution39,40 (Table 2). Because of its unspecific clinical presentation, TTS may be a challenging diagnosis and various clinical scenarios should be taken into account for differential diagnosis.42 ( Table 2)

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1

These authors have contributed equally to the study.

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