title: Basal hyperaemia is the primary abnormality of perfusion in Takotsubo cardiomyopathy: a quantitative cardiac perfusion positron emission tomography study.
abstract: OBJECTIVE
  Takotsubo cardiomyopathy (TTC) is characterized by acute completely reversible regional left ventricle (LV) akinesia and decreased tracer uptake in the akinetic region on semi-quantitative perfusion imaging. The latter may be due to normoperfusion of the akinetic mid/apical area and basal hyperperfusion. Our aim was to examine abnormalities of perfusion in TTC, and we hypothesized that basal hyperperfusion is the primary perfusion abnormality in the acute state.
  
  
  RESULTS
  Twenty-five patients were diagnosed with TTC due to (i) acute onset of symptoms, (ii) typical apical ballooning, (iii) absence of significant coronary disease, and (iv) complete remission on 4-month follow-up. The patients underwent coronary angiography (CAG), echocardiography, cardiac magnetic resonance imaging (CMR), and (13)NH3/(82)Rb positron emission tomography (PET) in the acute state and-except CAG-on follow-up. Patients initially had severe heart failure, mid/apical oedema but no infarction, and a rise in cardiac biomarkers. On initial perfusion PET imaging, eight patients appeared to have normal, whereas 17 patients had impaired LV perfusion. In the latter, flow in the basal region was increased in the acute state (1.5 ± 0.1 vs. 1.2 ± 0.1 mL/g/minRPP-corrected, P < 0.01), whereas midventricular (1.7 ± 0.1 vs. 1.6 ± 0.1 mL/g/minRPP-corrected, P = 0.21) and apical (1.4 ± 0.1 vs. 1.5 ± 0.1 mL/g/minRPP-corrected, P = 0.36) flow was unchanged between acute and follow-up, and within normal range.
  
  
  CONCLUSIONS
  Our results suggest an abnormal LV perfusion distribution in the acute state of TTC with basal hyperperfusion and a normoperfused akinetic region. The proportion of patients without visualized perfusion abnormalities in the acute state may represent a subgroup with fast remission.
authors: Department of Clinical Physiology, Nuclear Medicine and PET, Centre of Diagnostic Investigation, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark thomas.emil.christensen@regionh.dk.
authors: Thomas Emil
authors: TE
authors: Christensen
authors: Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Kiril Aleksov
authors: KA
authors: Ahtarovski
authors: Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Lia Evi
authors: LE
authors: Bang
authors: Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Lene
authors: L
authors: Holmvang
authors: Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Helle
authors: H
authors: Søholm
authors: Department of Clinical Physiology, Nuclear Medicine and PET, Centre of Diagnostic Investigation, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Adam Ali
authors: AA
authors: Ghotbi
authors: Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Hedvig
authors: H
authors: Andersson
authors: Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Niels
authors: N
authors: Vejlstrup
authors: Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Nikolaj
authors: N
authors: Ihlemann
authors: Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Copenhagen, Denmark.
authors: Thomas
authors: T
authors: Engstrøm
authors: Cluster for Molecular Imaging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
authors: Andreas
authors: A
authors: Kjær
authors: Department of Clinical Physiology, Nuclear Medicine and PET, Centre of Diagnostic Investigation, Copenhagen University Hospital, Blegdamsvej 9, Copenhagen 2100, Denmark.
authors: Philip
authors: P
authors: Hasbak
mesh_terms: D000368:Aged; D015415:Biomarkers / Q000097:blood; D017023:Coronary Angiography; D004452:Echocardiography; D004562:Electrocardiography; D005260:Female; D006801:Humans; D006940:Hyperemia; D008279:Magnetic Resonance Imaging; D008297:Male; D055414:Myocardial Perfusion Imaging / Q000379:methods*; D049268:Positron-Emission Tomography; D019275:Radiopharmaceuticals; D012414:Rubidium Radioisotopes; D054549:Takotsubo Cardiomyopathy / Q000000981:diagnostic imaging* / Q000503:physiopathology*; D018487:Ventricular Dysfunction, Left / Q000000981:diagnostic imaging* / Q000503:physiopathology*
chemical_list: D015415:Biomarkers; D019275:Radiopharmaceuticals; D012414:Rubidium Radioisotopes
keywords: Takotsubo cardiomyopathy; apical ballooning; cardiac MR; perfusion PET; reversible heart failure