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1 J Cardiol 2005 Dec; 466: : Atypical Takotsubo Cardiomyopathy With Preservation of Apical Contraction : A Case Report Including Pathological Findings Mitsunori Hiroto Hideyuki Hisashi Kenzo Nobuya Miri OHTSUBO, MD SAKAI, MD TAKANO, MD KON, MD OKAMOTO, MD 1 YOSHIDA, MD 2 FUJITA, MD 3 Abstract A 60-year-old woman presented with sudden chest and back pain. Electrocardiography suggested anterior myocardial infarction but coronary angiography revealed no significant stenosis in the coronary artery. Left ventriculography revealed akinesis of the mid ventricle and preserved contraction of the apical wall. The clinical condition of atypical left ventricular akinesia was suggested to be the same as conventionally reported typical takotsubo cardiomyopathy. Repeated left ventriculography revealed the abnormal wall motion had disappeared. The findings of endomyocardial biopsy were compatible with takotsubo cardiomyopathy. Although the clinical presentation of the left ventricle is atypical, the pathological findings may be the same as typical takatsubo cardiomyopathy. J Cardiol 2005 Dec ; 466: Key Words Cardiomyopathies, other takotsubo Pathology endomyocardial biopsy Contractility preserved apical contraction , : ; 2 ; 3 Divisions of Cardiology and 1 Pathology, Iwamizawa Rousai Hospital, Hokkaido ; 2 Division of Internal Medicine, Obihiro Kousei General Hospital, Hokkaido ; 3 Division of Pathology, Shinnittetsu Muroran General Hospital, Hokkaido Address for correspondence : OHTSUBO M, MD, Division of Cardiology, Iwamizawa Rousai Hospital, Higashi 165, 4-Jo, Iwamizawa, Hokkaido ; emypp228@ybb.ne.jp Manuscript received April 19, 2005; revised June 20, 2005; accepted July 15,
2 238 Fig. 1 Serial electrocardiograms ST elevation was noticed at 2 3 on day 1, but recovered gradually. Marked T wave depression appeared at, al, and 2 6 on day 3. These T wave changes normalized gradually but had not recovered completely on day 23. : : : : 40 / : ST : 152cm55kg 158/85 mmhg68/min X : 53% : 68/min 3 ST 1 3 R 2 Fig. 1 : 9,050/l 212 IU/l : 2 3 ST Fig. 2 Fig % 5 1 ST34 al 6 T QT 2 QT-T3 1 3 R Fig. 1 J Cardiol 2005 Dec; 466:
3 239 Fig. 2 Emergent coronary angiograms Neither the left coronary arteryleftnor the right coronary arteryrightshowed significant stenosis. Fig. 3 Emergent left ventriculograms Left: Left ventriculogram at diastole. Right : Left ventriculogram at systole. Akinesis of mid ventricle was seen, but the contraction of apical wall was preserved. 212IU/l 23 Fig % Fig. 5 J Cardiol 2005 Dec; 466:
4 240 大坪 酒井 高野 ほか Fig. 4 Follow-up left ventriculograms Left : Left ventriculogram at diastole on day 23. Right : Left ventriculogram at systole on day 23. Remarkable amelioration of left ventricular wall motion was observed. Fig. 5 Photomicrographs of biopsy specimens Left : Hematoxylin-eosin stain 400 showing myocytolysis. Right : Azan stain 200 showing microscopic fibrosis. る可能性を考えて詳細な問診を行ったが まったく のような症例を 従来から報告されている心尖部が無 普通の生活をしていた という返答のみであり 明ら 収縮となるたこつぼ心筋障害と同様に考えてよいか議 かな契機を特定することはできなかった 入院中の臨 論の余地がある 病理学的検討を加えることも重要で 床経過は良好であり 高血圧症の治療歴があるため あると考えられるが 本疾患における病理報告は数少 Ca 拮抗薬を処方して退院とした なく 病理学的に統一された見解はない しかし 心 考 尖部が無収縮になる定型例においては心筋の融解や脱 察 落 巣状線維化 間質浮腫などが報告されており6,7 最近 心尖部収縮が保たれた 非定型的 と表現す べきたこつぼ心筋障害の報告が散見されるが 3,4 こ これらは比較的共通した所見のようである 一方 我々の知る限り心尖部収縮が保たれた非定型的たこつ J Cardiol 2005 Dec; 46 6 :
5 ,11 1,12 1,5 60 J Cardiol 2005 Dec; 466: : Ampulla or Amphora: 2000; 48 : : spasm stunned myocardiumin : 1990; pp Tawarahara K, Mikami T, Matoh F, Odagiri K, Saitoh N, Kurata C : e 1; 65Suppl-A: 420abstr 4Kadota K, Mitsudo K, Inoue K, Goto T, Fujii S, Yamamoto H, Fuku Y, Takenaka S, Hirono A, Tanaka H, Taba M, Saihara K, Ikeda A, Kojima Y, Maekawa J, Maekawa S, Takahashi N, Saeki H, Nakamura Y : Two types of transient left ventricular wall motion abnormality mimicking acute coronary syndrome. Circ J 2005; 69Suppl: 534 abstr 5 : Circ J 2002 ; 66 Suppl: 913abstr 6 J Cardiol 2005 Dec; 466:
6 242 : Stunned Myocardium ; 44 : : Heart View 2004; 8 : Dote K, Sato H, Tateishi H, Uchida T, Ishihara M : Myocardial stunning due to simultaneous multivessel coronary spasms : A review of 5 cases. J Cardiol 1991 ; 21 : in Jpn with Eng abstr 9Kurisu S, Inoue I, Kawagoe T, Ishihara M, Shimatani Y, Nishioka K, Umemura T, Nakamura S, Yoshida M, Sato H: Myocardial perfusion and fatty acid metabolism in patients with tako-tsubo-like left ventricular dysfunction. J Am Coll Cardiol 2003 ; 41: Lee JC, Sponenberg DP: Role of alpha 1-adrenoceptors in norepinephrine-induced cardiomyopathy. Am J Pathol 1985 ; 121: Simons M, Downing SE : Coronary vasoconstriction and catecholamine cardiomyopathy. Am Heart J 1985 ; 109 : Pavin D, Le Breton H, Daubert C: Human stress cardiomyopathy mimicking acute myocardial syndrome. Heart 1997 ; 78: J Cardiol 2005 Dec; 466:
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