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Persisting myocardial sympathetic dysfunction in takotsubo cardiomyopathy.

Verberne HJ, van der Heijden DJ, van Eck-Smit BL, Somsen GA - J Nucl Cardiol (2009)

View Article: PubMed Central - PubMed

Affiliation: Department of Nuclear Medicine, Academic Medical Center, University of Amsterdam, P.O. Box 22700, Amsterdam, 1100 DE, The Netherlands. h.j.verberne@amc.uva.nl

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The electrocardiography (ECG) showed an acute anterior wall infarction (Figure 1)... Acute coronary angiography was performed but no significant coronary artery disease was found... Shortly after treatment with intravenous inotropics, and ACE inhibition the patient became hemodynamically stable and metoprolol was added... Cardiac MRI did not show late contrast enhancement which excludes myocardial fibrosis and myocardial infarction as the cause of the hemodynamic instability... The diagnosis of a stress-induced cardiomyopathy, apical ballooning syndrome or TC was based on the presence of the typical symptoms and signs of an anterior wall infarction after a highly stressful moment (a lifetime crisis), combined with normal coronary angiography, LV apical ballooning, no signs of late contrast enhancement on MRI scanning, and rapid recovery of LV function... However, in the case report of Moreo et al I-MIBG myocardial uptake increased, after a 2-month treatment with carvedilol... Moreover, in patients with heart failure β-adrenoreceptor-blockers and ACE inhibitors are associated with an increase in I-MIBG uptake and reduced washout., In our patient ACE inhibition was discontinued after the acute phase and the β-adrenoreceptor-blocker was continued... Another possible confounding factor of persisting abnormal I-MIBG scintigraphic findings is denervation due to a previous myocardial infarction... In our patient, myocardial sympathetic activity was increased in the early phase of TC... Normalization of myocardial I-MIBG uptake has been described in several case reports., This is the first report showing persisting sympathetic dysfunction in a patient with TC after complete normalization of the LV function and no signs of late enhancement on MRI... In the present case, the patient experienced the same symptoms after an emotional event several years earlier which may have been an earlier episode of TC... Predictors of TC recurrence are not known... As TC is associated with a hyperadrenergic state, the persisting increased myocardial sympathetic activity may have prognostic implications... Therefore, myocardial I-MIBG scintigraphy may identify patients at risk for the recurrence of TC.

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123I-MIBG scintigraphy: images on the left were made 15 min postinjection (p.i.) of 123I-MIBG (early) and the images on the right were made 4 h p.i. (late). Upper left panel shows the regions of interest over the myocardium and mediastinum for the calculation of the semiquantitative parameters of 123I-MIBG myocardial uptake and washout. 123I-MIBG images 4 days after hospital admission, show severely reduced myocardial uptake (A). Semiquantitative analysis of the myocardial uptake confirmed the visual interpretation (early heart/mediastinal (H/M) ratio: 1.54, late H/M: 1.26 and myocardial washout of 123I-MIBG: 18%). Three (B) and seven months (C) after hospital admission 123I-MIBG myocardial uptake and washout remained abnormal. The semiquantitative parameters remained abnormal after 3 months (early H/M: 1.78, late H/M: 1.33, and myocardial washout of 123I-MIBG: 25%) and after 7 months (early H/M: 1.66, late H/M: 1.13, and myocardial washout of 123I-MIBG: 32%). Due to the diffuse reduced myocardial 123I-MIBG uptake SPECT images could not reliably be reconstructed
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Fig3: 123I-MIBG scintigraphy: images on the left were made 15 min postinjection (p.i.) of 123I-MIBG (early) and the images on the right were made 4 h p.i. (late). Upper left panel shows the regions of interest over the myocardium and mediastinum for the calculation of the semiquantitative parameters of 123I-MIBG myocardial uptake and washout. 123I-MIBG images 4 days after hospital admission, show severely reduced myocardial uptake (A). Semiquantitative analysis of the myocardial uptake confirmed the visual interpretation (early heart/mediastinal (H/M) ratio: 1.54, late H/M: 1.26 and myocardial washout of 123I-MIBG: 18%). Three (B) and seven months (C) after hospital admission 123I-MIBG myocardial uptake and washout remained abnormal. The semiquantitative parameters remained abnormal after 3 months (early H/M: 1.78, late H/M: 1.33, and myocardial washout of 123I-MIBG: 25%) and after 7 months (early H/M: 1.66, late H/M: 1.13, and myocardial washout of 123I-MIBG: 32%). Due to the diffuse reduced myocardial 123I-MIBG uptake SPECT images could not reliably be reconstructed

Mentions: Cardiac MRI did not show late contrast enhancement which excludes myocardial fibrosis and myocardial infarction as the cause of the hemodynamic instability. Myocardial 123I-metaiodobenzylguanidine (123I-MIBG, a radiolabelled noradrenalin analog) scintigraphy, performed 4 days after admission, showed diffuse reduced myocardial uptake and increased washout of 123I-MIBG which reflects impaired sympathetic neuronal function and increased sympathetic activity, respectively (Figure 3A). Cardiac ultrasound was repeated at 3 and 7 months and showed no mitral regurgitation and a normalized LV function. However, cardiac sympathetic neuronal function and activity remained abnormal as was shown by 123I-MIBG scintigraphy at 3 and 7 months (Figure 3B and C, respectively).Figure 3


Persisting myocardial sympathetic dysfunction in takotsubo cardiomyopathy.

Verberne HJ, van der Heijden DJ, van Eck-Smit BL, Somsen GA - J Nucl Cardiol (2009)

123I-MIBG scintigraphy: images on the left were made 15 min postinjection (p.i.) of 123I-MIBG (early) and the images on the right were made 4 h p.i. (late). Upper left panel shows the regions of interest over the myocardium and mediastinum for the calculation of the semiquantitative parameters of 123I-MIBG myocardial uptake and washout. 123I-MIBG images 4 days after hospital admission, show severely reduced myocardial uptake (A). Semiquantitative analysis of the myocardial uptake confirmed the visual interpretation (early heart/mediastinal (H/M) ratio: 1.54, late H/M: 1.26 and myocardial washout of 123I-MIBG: 18%). Three (B) and seven months (C) after hospital admission 123I-MIBG myocardial uptake and washout remained abnormal. The semiquantitative parameters remained abnormal after 3 months (early H/M: 1.78, late H/M: 1.33, and myocardial washout of 123I-MIBG: 25%) and after 7 months (early H/M: 1.66, late H/M: 1.13, and myocardial washout of 123I-MIBG: 32%). Due to the diffuse reduced myocardial 123I-MIBG uptake SPECT images could not reliably be reconstructed
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Related In: Results  -  Collection

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getmorefigures.php?uid=PMC2697369&req=5

Fig3: 123I-MIBG scintigraphy: images on the left were made 15 min postinjection (p.i.) of 123I-MIBG (early) and the images on the right were made 4 h p.i. (late). Upper left panel shows the regions of interest over the myocardium and mediastinum for the calculation of the semiquantitative parameters of 123I-MIBG myocardial uptake and washout. 123I-MIBG images 4 days after hospital admission, show severely reduced myocardial uptake (A). Semiquantitative analysis of the myocardial uptake confirmed the visual interpretation (early heart/mediastinal (H/M) ratio: 1.54, late H/M: 1.26 and myocardial washout of 123I-MIBG: 18%). Three (B) and seven months (C) after hospital admission 123I-MIBG myocardial uptake and washout remained abnormal. The semiquantitative parameters remained abnormal after 3 months (early H/M: 1.78, late H/M: 1.33, and myocardial washout of 123I-MIBG: 25%) and after 7 months (early H/M: 1.66, late H/M: 1.13, and myocardial washout of 123I-MIBG: 32%). Due to the diffuse reduced myocardial 123I-MIBG uptake SPECT images could not reliably be reconstructed
Mentions: Cardiac MRI did not show late contrast enhancement which excludes myocardial fibrosis and myocardial infarction as the cause of the hemodynamic instability. Myocardial 123I-metaiodobenzylguanidine (123I-MIBG, a radiolabelled noradrenalin analog) scintigraphy, performed 4 days after admission, showed diffuse reduced myocardial uptake and increased washout of 123I-MIBG which reflects impaired sympathetic neuronal function and increased sympathetic activity, respectively (Figure 3A). Cardiac ultrasound was repeated at 3 and 7 months and showed no mitral regurgitation and a normalized LV function. However, cardiac sympathetic neuronal function and activity remained abnormal as was shown by 123I-MIBG scintigraphy at 3 and 7 months (Figure 3B and C, respectively).Figure 3

View Article: PubMed Central - PubMed

Affiliation: Department of Nuclear Medicine, Academic Medical Center, University of Amsterdam, P.O. Box 22700, Amsterdam, 1100 DE, The Netherlands. h.j.verberne@amc.uva.nl

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

The electrocardiography (ECG) showed an acute anterior wall infarction (Figure 1)... Acute coronary angiography was performed but no significant coronary artery disease was found... Shortly after treatment with intravenous inotropics, and ACE inhibition the patient became hemodynamically stable and metoprolol was added... Cardiac MRI did not show late contrast enhancement which excludes myocardial fibrosis and myocardial infarction as the cause of the hemodynamic instability... The diagnosis of a stress-induced cardiomyopathy, apical ballooning syndrome or TC was based on the presence of the typical symptoms and signs of an anterior wall infarction after a highly stressful moment (a lifetime crisis), combined with normal coronary angiography, LV apical ballooning, no signs of late contrast enhancement on MRI scanning, and rapid recovery of LV function... However, in the case report of Moreo et al I-MIBG myocardial uptake increased, after a 2-month treatment with carvedilol... Moreover, in patients with heart failure β-adrenoreceptor-blockers and ACE inhibitors are associated with an increase in I-MIBG uptake and reduced washout., In our patient ACE inhibition was discontinued after the acute phase and the β-adrenoreceptor-blocker was continued... Another possible confounding factor of persisting abnormal I-MIBG scintigraphic findings is denervation due to a previous myocardial infarction... In our patient, myocardial sympathetic activity was increased in the early phase of TC... Normalization of myocardial I-MIBG uptake has been described in several case reports., This is the first report showing persisting sympathetic dysfunction in a patient with TC after complete normalization of the LV function and no signs of late enhancement on MRI... In the present case, the patient experienced the same symptoms after an emotional event several years earlier which may have been an earlier episode of TC... Predictors of TC recurrence are not known... As TC is associated with a hyperadrenergic state, the persisting increased myocardial sympathetic activity may have prognostic implications... Therefore, myocardial I-MIBG scintigraphy may identify patients at risk for the recurrence of TC.

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