Concominant hypertrophic and takotsubo cardiomyopathy; cardiac magnetic resonance with parametric mapping findings after acute phase

Excerpt

A 50 year old female patient admitted to the emergency department with chest pain for past one week. Electrocardiogram revealed anteroseptal wall ischemia. Echocardiography indicated normal ejection fraction with severe hypokinesis of the apical wall. She had markedly thickened septum and obstruction at rest in the outflow tract, with a peak velocity of 323 cm/s and an estimated peak gradient of 42 mmHg indicating hypertrophic cardiomyopathy (HCM). Coronary angiography showed slow coronary flow at left anterior descending artery. She was depressed and anxious. She had history of losing a close relative in a car accident 2 weeks ago. Therefore, even though apical ballooning was not shown in echocardiography, cardiac magnetic resonance (CMR) was planned with suspicion of Takotsubo Cardiomyopathy (TCM) at subacute phase. On performed CMR, at the apical level of the left ventricle, the wall was diffuse edematous and T2 time was 62 millisecond (msn) and prolonged (T2 time, normal range 44 to 56 msn in our center). At this level, wall motion was hypokinetic. Delayed myocardial enhancement indicating infarct/fibrosis did not develop in this region. T2 mapping sequences suggested TCM (Fig. 1a, b). Because of performing imaging after acute phase, typical apical ballooning did not occur in CMR as in echocardiography. In addition, there was significant delayed myocardial enhancement indicating fibrosis at the anterior junction of the right-left ventricle at the basal level with the basal anteroseptal wall. It was also confirmed on post-contrast T1 mapping images (Fig. 1c, d). In hypertrophy, contrast enhancements were expected in this region and indicated focal fibrosis. These findings confirmed HCM diagnosis. HCM and TCM are two distinct diseases with different pathophysiology. Previous studies reported their concurrency [1, 2]. Making the diagnosis of a concomitant HCM and TCM may be challenging especially after acute phase but CMR imaging provided diagnosis of both HCM and TCM effectively in this case. …