Ultrasound Case 091

Presentation

A 56 year old woman presents with chest pain and shortness of breath. Her ECG demonstrates widespread precordial ischaemic change.

View 2: Parasternal short axis view
View 3: Parasternal short axis view more distally
View 4: Apical 4 chamber view
View 5: EPSS
Ultrasound Top 100 091 05 EPSS
View 6: Fractional Shortening
Ultrasound Top 100 091 06 fractional shortening

Describe and interpret these scans

IMAGE INTERPRETATION

Image 1: Parasternal long axis. This view does not include the distal left ventricle particularly well. Nevertheless relatively normal appearing left sided valves are seen, and the base of the LV is seen vigorously. Distal to this is appears there is circumferential dysfunction with systolic ballooning of the distal left ventricle in the characteristic “octopus trap” shape. Takotsubo cardiomyopathy.

Ultrasound Top 100 091 07 Key to image 1
Key to image 1

Image 2: Parasternal short axis view. Directed toward the base of the LV and contractility looks good.

Image 3: Parasternal short axis view more distally – and there is circumferential dysfunction and ballooning of the LV.

Image 4: Apical 4 chamber view. This demonstrates the distal apical ballooning seen with Takotsubo cardiomyopathy together with hypercontraction of the basal segment.

Image 5: EPSS or end point septal separation – a method some use to rapidly determine global LV function. If the anterior leaflet of the mitral valve gets to within 7mm of the the septum LV function is considered good. In this patient the septum and anterior leaflet almost meet, but this does not reflect global LV function. The basal septum is hyperdynamic, coming in toward the anterior leaflet more than usual. Focusing on the EPSS data point alone gives an erroneous impression of overall function.

Image 6: Fractional shortening as a measure of overall LV function is also fraught with difficulty. Here the basal walls are used as representative of the entire ventricle and as they are hyperdynamic dramatically overestimate ejection fraction.


CLINICAL CORRELATION

Takotsubo cardiomyopathy

Takotsubo cardiomyopathy is also known as stress cardiomyopathy or broken heart syndrome. It is a stress induced temporary cardiomyopathy. The typical echocardiographic features of Takotsubo cardiomyopathy and systolic ballooning of the apex and hypercontraction of the basal segment.

Although it can be suspected clinically and on echocardiography; angiography is performed to exclude acute coronary syndromes.

In this case the coronary vessels were pristine.

Key points:

  1. Angiography is required to exclude ACS.
  2. Do not estimate LV function using techniques that only assess the basal segments.

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An Emergency physician based in Perth, Western Australia. Professionally my passion lies in integrating advanced diagnostic and procedural ultrasound into clinical assessment and management of the undifferentiated patient. Sharing hard fought knowledge with innovative educational techniques to ensure knowledge translation and dissemination is my goal. Family, wild coastlines, native forests, and tinkering in the shed fills the rest of my contented time. | SonoCPDUltrasound library | Top 100 | @thesonocave |

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