Follow-up in Tako-tsubo cardiomyopathy by real-time three-dimensional echocardiography

A 77-year-old woman was admitted for acute chest pain after a brief episode of severe vertigo and headache. Initial troponin I levels were negative (<0.03 μg/l), but increased to a maximum of 1.7 μg/l on day 2 after admission.

(A) Regional volume curves by quantitative real-time three-dimensional transthoracic echocardiography 3 days after admission normalised to end-diastolic volume. The smallest change in regional volume is documented in the apical segments. (B) At day 20 the regional volume changes are more homogeneous, but significant post-systolic contraction is present in several segments (arrows). (C) Further improvement is seen on day 45 with less post-systolic contraction. (D) Bulls-eye view with colour-coding for the 16 analysed segments.

The ECG showed an incomplete right-bundle branch block and slight elevation of the ST-segment in V₁–V₃. Coronary artery disease was excluded by coronary angiography. Left ventricular (LV) fluoroscopy and quantitative real-time three-dimensional transthoracic echocardiography (rt-3D; GE Vivid 7 Dimension, GE Healthcare, Horten, Norway) both demonstrated typical apical ballooning consistent with Tako-tsubo cardiomyopathy (panel A, videos 1 and 3). Global LV function by ejection fraction (EF), end-diastolic (EDV) and end-systolic volume (ESV) was only slightly impaired owing to compensatory hyperkinesia of the basal segments (EF 55%, EDV 71 ml, ESV 32 ml).

At 3 weeks’ follow-up the apical segments had almost completely recovered (panel B, videos 2 and 4), but showed persistent post-systolic contraction by quantitative rt-3DE (panel B, arrows). Further improvement with less post-systolic contraction was demonstrated at day 45 (EF 65%, EDV 60, ESV 21 ml, panel C).

Rt-3DE allows a rapid and comprehensive analysis of the typical pattern of wall motion abnormalities in Tako-tsubo cardiomyopathy and provides a precise determination of LV volumes and shape.