Regional wall motion abnormality in apical ballooning syndrome (Takotsubo/stress cardiomyopathy): importance of biplane left ventriculography for differentiating from spontaneously aborted anterior myocardial infarction

  • Sandeep M. Patel
  • Ryan J. Lennon
  • Abhiram PrasadEmail author
Original Paper


Understanding the precise distribution of the regional wall motion abnormality (RWMA) in apical ballooning syndrome (ABS) is important because the cardiomyopathy can mimic an acute anterior ST-elevation myocardial infarction (STEMI). The aim of the study was to quantify the severity and distribution of RWMA in ABS, compare it to anterior STEMI, and correlate with clinical features. RWMA (normal = 1, hypokinetic = 2, akinetic = 3) was quantified from the biplane left ventriculogram using a nine-segment model in 95 ABS and 17 anterior STEMI patients at the time of their presentation. Regional wall motion score index (RWMSI) was higher in ABS [2.1 (1.9, 2.1)] compared to anterior STEMI [2.0 (1.8, 2.0)], P = 0.024]. The region that most clearly differentiated ABS from anterior STEMI was the posterolateral segment (sensitivity 81% and specificity 100%) which was hypocontractile in 81% of ABS, but none of the STEMI patients (P < 0.001). RWMSI in ABS had a modest positive correlation with the troponin T levels (r = 0.23, P = 0.029). Patients with ABS with ST-segment elevation had the highest RWMSI [2.1(2.0, 2.2)], while those with non specific changes had the lowest [1.9 (1.8, 2.1)] (P = 0.007). In conclusion, patients with ABS have greater and more diffuse RWMA compared to anterior STEMI. The presence of systolic dysfunction in the posterolateral segment in the left anterior oblique projection of the left ventriculogram most accurately distinguishes ABS from an anterior STEMI highlighting the utility of biplane angiography for this purpose. The severity of RWMA correlates with the extent of troponin release and ECG abnormality.


Apical ballooning syndrome Takotsubo cardiomyopathy Regional wall motion abnormality 



Apical ballooning syndrome




Ejection fraction


Left anterior oblique


Left ventricle


Right anterior oblique


Regional wall motion abnormality


Regional wall motion score index


ST elevation myocardial infarction


Conflicts of interest



  1. 1.
    Prasad A (2007) Apical ballooning syndrome: an important differential diagnosis of acute myocardial infarction. Circulation 115:e56–e59PubMedCrossRefGoogle Scholar
  2. 2.
    Prasad A, Lerman A, Rihal CS (2008) Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J 155:408–417PubMedCrossRefGoogle Scholar
  3. 3.
    Haghi D, Fluechter S, Suselbeck T, Kaden JJ, Borggrefe M, Papavassiliu T (2007) Cardiovascular magnetic resonance findings in typical versus atypical forms of the acute apical ballooning syndrome (Takotsubo cardiomyopathy). Int J Cardiol 120:205–211PubMedCrossRefGoogle Scholar
  4. 4.
    Mitchell JH, Hadden TB, Wilson JM, Achari A, Muthupillai R, Flamm SD (2007) Clinical features and usefulness of cardiac magnetic resonance imaging in assessing myocardial viability and prognosis in Takotsubo cardiomyopathy (transient left ventricular apical ballooning syndrome). Am J Cardiol 100:296–301PubMedCrossRefGoogle Scholar
  5. 5.
    Sharkey SW, Lesser JR, Zenovich AG, Maron MS, Lindberg J, Longe TF, Maron BJ (2005) Acute and reversible cardiomyopathy provoked by stress in women from the United States. Circulation 111:472–479PubMedCrossRefGoogle Scholar
  6. 6.
    Singh NK, Rumman S, Mikell FL, Nallamothu N, Rangaswamy C (2009) Stress cardiomyopathy: Clinical and ventriculographic characteristics in 107 North American subjects. Int J CardiolGoogle Scholar
  7. 7.
    Chao T, Lindsay J, Collins S, Woldeyes L, Joshi SB, Steinberg DH, Satler LF, Kent KM, Suddath WO, Pichard AD, Waksman R (2009) Can acute occlusion of the left anterior descending coronary artery produce a typical “Takotsubo” left ventricular contraction pattern? Am J Cardiol 104:202–204PubMedCrossRefGoogle Scholar
  8. 8.
    Ibanez B, Choi BG, Navarro F, Farre J (2006) Tako-tsubo syndrome: a form of spontaneous aborted myocardial infarction? Eur Heart J 27:1509–1510PubMedCrossRefGoogle Scholar
  9. 9.
    Ibanez B, Benezet-Mazuecos J, Navarro F, Farre J (2006) Takotsubo syndrome: a Bayesian approach to interpreting its pathogenesis. Mayo Clin Proc 81:732–735PubMedCrossRefGoogle Scholar
  10. 10.
    Dib C, Asirvatham S, Elesber A, Rihal C, Friedman P, Prasad A (2009) Clinical correlates and prognostic significance of electrocardiographic abnormalities in apical ballooning syndrome (Takotsubo/stress-induced cardiomyopathy). Am Heart J 157:933–938PubMedCrossRefGoogle Scholar
  11. 11.
    Hurst RT, Askew JW, Reuss CS, Lee RW, Sweeney JP, Fortuin FD, Oh JK, Tajik AJ (2006) Transient midventricular ballooning syndrome: a new variant. J Am Coll Cardiol 48:579–583PubMedCrossRefGoogle Scholar
  12. 12.
    Giannitsis E, Steen H, Kurz K, Ivandic B, Simon AC, Futterer S, Schild C, Isfort P, Jaffe AS, Katus HA (2008) Cardiac magnetic resonance imaging study for quantification of infarct size comparing directly serial versus single time-point measurements of cardiac troponin T. J Am Coll Cardiol 51:307–314PubMedCrossRefGoogle Scholar
  13. 13.
    Elesber A, Lerman A, Bybee KA, Murphy JG, Barsness G, Singh M, Rihal CS, Prasad A (2006) Myocardial perfusion in apical ballooning syndrome correlate of myocardial injury. Am Heart J 152(469):e9–e13PubMedGoogle Scholar
  14. 14.
    Hoyt J, Lerman A, Lennon RJ, Rihal CS, Prasad A (2009) Left anterior descending artery length and coronary atherosclerosis in apical ballooning syndrome (Takotsubo/stress induced cardiomyopathy). Int J CardiolGoogle Scholar
  15. 15.
    Park SM, Prasad A, Rihal C, Bell MR, Oh JK (2009) Left ventricular systolic and diastolic function in patients with apical ballooning syndrome compared with patients with acute anterior ST-segment elevation myocardial infarction: a functional paradox. Mayo Clin Proc 84:514–521PubMedCrossRefGoogle Scholar
  16. 16.
    Hahn JY, Gwon HC, Park SW, Choi SH, Choi JH, Choi JO, Lee SC, On YK, Kim JS, Kim DK, Jeon ES, Lee SH, Hong KP, Park JE (2007) The clinical features of transient left ventricular nonapical ballooning syndrome: comparison with apical ballooning syndrome. Am Heart J 154:1166–1173PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, B.V. 2011

Authors and Affiliations

  • Sandeep M. Patel
    • 1
  • Ryan J. Lennon
    • 1
  • Abhiram Prasad
    • 1
    Email author
  1. 1.The Division of Cardiovascular Diseases, Department of Internal MedicineMayo ClinicRochesterUSA

Personalised recommendations