European Journal of Echocardiography 2008 9(1):78-79; doi:10.1016/j.euje.2007.01.002
Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2007. For permissions please email: journals.permissions@oxfordjournals.org.
Assessment of coronary flow reserve by transthoracic Doppler echocardiography in left apical ballooning syndrome
Patrick Meimoun1,*,
Dorothée Malaquin1,
Tahar Benali1 and
Christophe Tribouilloy2
1 Department of Cardiology and Intensive Care Unit, Compiègne Hospital, Compiègne, France
2 Department of Cardiology, Centre Hospitalier Universitaire d'Amiens, France
Received 21 October 2006; accepted after revision 6 January 2007; online publish-ahead-of-print 28 February 2007.
* Corresponding author. Service de Cardiologie et Soins Intensifs, Centre Hospitalier de Compiègne, 8 rue Henri Adnot, 60200 Compiègne, France. Tel: +33 3 44 23 62 39; fax: +33 3 44 23 62 38. E-mail address: patrickmeimoun{at}free.fr
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Abstract
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We present the time course of transthoracic coronary flow reserve
in the left anterior descending artery in a patient who suffered
a transient left apical ballooning syndrome.
Keywords: Left apical ballooning syndrome; Tako-tsubo; Transthoracic Doppler echocardiography; Coronary flow reserve
A 73-year-old woman was admitted to our coronary care unit with chest pain, starting 2 h before. She had a history of hypertension and dyslipidemia. Her husband had been hospitalized in emergency a few hours before and he was referred for acute surgery. Physical examination revealed a mild heart murmur and no signs of heart failure. ECG showed slow R wave progression in the precordial leads. Sublingual trinitrin had no effect. Treatment for an acute coronary syndrome was started, including aspirin, low molecular weight heparin, and clopidogrel. Transthoracic echocardiography (TTE) revealed balloon-like left ventricular (LV) wall motion abnormalities (WMA) at the apex with hypercontraction of the basal segments, mild mitral regurgitation, normal LV mild-cavity dimensions and no LV obstruction (Figure 1A). The LV angiogram showed typical apical ballooning (Figure 2) and coronary angiography showed normal coronary arteries (Figure 2). Mild elevation of troponin was present (peak 0.84 µg/l). Twenty-four hours after hospitalisation, transthoracic coronary flow reserve (TTE-CFR) was measured in the distal part of the left anterior descending artery (LAD), using intravenous adenosine infusion (0.14 mg/kg/min over 2 min).1 The mean diastolic CFR was 2.1 (Figure 2A). After 2 days, the ECG showed diffuse T waves inversion and a QTc interval of 426 ms. No complication occurred during the hospital course. Four weeks later, a new TTE revealed a normalisation of LV wall motion (Figure 1B) while TTE-CFR, performed with the same way as initially, was 2.7 (Figure 3B).The increase of TTE-CFR was confirmed 3 months later with a value of 3 (Figure 3C).
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Figure 3 Coronary flow velocity profile at baseline and hyperemic conditions showing the time course of CFR. (A) in the acute phase; (B) at 1 month and (C) at 3 months. At baseline the heart rates were 65/min, 63/min and 60/min, respectively, and blood pressure 120/60 mmHg, 150/60 mmHg, and 145/60 mmHg, respectively.
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The pathophysiology of the transient cardiomyopathy called tako-tsubo
or left apical ballooning syndrome, which affects post-menopausal
women who experienced a stressful event, is still debated. Serial
non-invasive measurements of CFR in this case suggest transient
impairment of the coronary microcirculation during the acute
phase of the syndrome.
The improvement of the microcirculation parallels the regression of the WMA suggesting a relationship between these two variables.
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Reference
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- Meimoun P, Benali T, Sayah S, Luycx-Bore A, Boulanger J, Zemir H, et al. Evaluation of left anterior descending coronary artery stenosis of intermediate severity using transthoracic coronary flow reserve and dobutamine stress echocardiography. J Am Soc Echocardiog (2005) 12:1233–40.
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