Inflammation in takotsubo cardiomyopathy: Insights from cardiovascular magnetic resonance imaging

Objective: Takotsubo cardiomyopathy (TTC) is an increasingly recognised acute cardiac syndrome, whose underlying pathophysiological mechanisms remain unknown. Inflammation might play a role as this has been shown in endomyocardial biopsies. The aim of this study was to assess inflammatory parameters in patients with TTC using a comprehensive cardiovascular magnetic resonance imaging (CMR) approach. Methods: Thirty-seven patients with the suspected diagnosis of TTC underwent CMR. T2-weighted imaging to calculate the oedema ratio, T1-weighted imaging before and after contrast agent administration to calculate the global relative enhancement (gRE), and late gadolinium enhancement (LGE) imaging were performed. Results: In 11 patients CMR revealed the diagnosis of myocardial infarction (n=7; 19%) or myocarditis (n=4; 11%) with typical patterns of LGE. In all other patients (n=26; 70%), no LGE was detected consistent with the diagnosis of TTC. Of these, in 16 patients (62%) both inflammatory markers (oedema ratio and gRE) were elevated with concomitant pericardial effusion, indicating acute inflammation. Follow-up CMR after 3 months showed complete normalisation of left ventricular function and inflammatory parameters in the absence of LGE and pericardial effusion. Conclusion: This CMR study provides further insights into the pathophysiological mechanisms in TTC, supporting the contribution of an inflammatory process in the acute setting.