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1 J Cardiol 2006 Jan; 47 1 : No Reflow 1 Takotsubo Cardiomyopathy Manifesting as No Reflow Pattern in Coronary Flow by Transthoracic Doppler Echocardiography and Prolonged Recovery of Regional Left Ventricular Wall Motion Abnormality: A Case Report Etsuko Kiyoaki Kenji Soichiro Kenji Tetsuya Toru IKEDA, MD MAEKAWA, MD KAWAMOTO,MD FUKE, MD TAKAGAKI, MD SATO, MD HIOKA, MD Abstract A 80-year-old woman was admitted to our hospital because of chest pain. Electrocardiography revealed ST segment elevation in the, a L, and 1 5 leads. Echocardiography revealed left ventricular apical aneurysmal change with ejection fraction of 31%. Coronary angiography showed no abnormalities. Creatine kinase was not elevated in her clinical course. The diagnosis was takotsubo cardiomyopathy. Transthoracic Doppler echocardiography was performed on the 2nd hospital day. Coronary flow velocity pattern in the left anterior descending artery revealed shortened diastolic deceleration time 108 msec and systolic retrograde flow. Asynergy of the left ventricle gradually improved, but still persisted slightly at 6 months after discharge. Most patients with takotsubo cardiomyopathy have normal coronary flow velocity pattern in the acute phase. In this case, no reflow pattern of coronary flow was observed during prolonged recovery from left ventricular regional wall motion abnormality. J Cardiol 2006 Jan ; 47 1 : Key Words Cardiomyopathies, other takotsubo Coronary microcirculation no flow Doppler ultrasound no : Cardiovascular Medicine, Okayama Redcross General Hospital, Okayama Address for correspondence : MAEKAWA K, MD, Cardiovascular Medicine, Okayama Redcross General Hospital, Aoe 2 1 1, Okayama, Okayama Manuscript received June 22, 2005; revised August 30, 2005; accepted August 31,
2 40 池田 前川 川本 ほか Table 1 reflow パターンを示した症例を経験した 本症例は肺 うっ血を合併し 壁運動異常が遷延化するなど 通常 Urine と異なった臨床経過を示したので報告する 症 症 例 主 訴 : 胸部絞扼感 例 80 歳 女性 無職 Laboratory data on admission AIP 231 IU/l Glucose T-Bil 1.1 mg/dl Occult blood T-cho 159 mg/dl Urobilinogen TP 6.0 g/dl BS 153 mg/dl CK 107 IU/l Complete blood count /mm3 RBC 既往歴 : 高血圧 60 歳頃より を指摘されているが 11.0 g/dl Hb 非薬物療法で加療中 冠危険因子 : 喫煙 糖尿病 高脂血症 268 IU/l LDH Protein 12 IU/l CK-MB Ht 32.9% WBC 9,100 /mm3 Coagulation test 6.9 mg/dl CRP Neutro 77.7% Eosino 0.4% APTT 家族歴 : 特記事項なし Mono 3.8% Fibrinogen 現病歴 : 2004 年年 7 月 13 日朝 5 時頃より胸のつらさ Baso を自覚した 同日 10 時頃 近医を受診し 心電図で ST 上昇 トロポニン T 陽性が指摘され 急性心筋梗 0.5% Platelet 47.6 sec 384 mg/dl TnT 17.6% Lymph 14.9 sec PT Serum catecholamine /mm3 Blood chemistry Adrenaline 50 pg/ml Noradrenaline 522 pg/ml 塞の疑いで当院に緊急入院となった 誘因となりうる Na 明らかな精神的ストレスは認められていない K 3.6 meq/l Cl 108 meq/l Adrenaline BUN 12.5 mg/dl Noradrenaline 106.8μg/day Cr 0.54 mg/dl 入院時身体所見 : 身長 144 cm 体重 35 kg 体温 38.0 C 血圧 110/68 mmhg 脈拍 96/min 整 頸静脈 怒張なし 肺野は両側でラ音を聴取した 心雑音なし 腹部異常なし 下腿浮腫なし 140 meq/l GOT 24 IU/l GPT 15 IU/l 13 pg/ml Dopamine Urine catecholamine 6.6μg/day 229.5μg/day Dopamine 1,220 pg/ml BNP 入院時検査成績 Table 1 : GOT 24 IU/l GPT 15 IU/l A B C D E A Ⅰ V1 Ⅱ V2 Ⅲ V3 B C D E avr V4 avl V5 avf V6 Fig. 1 Serial electrocardiograms demonstrating changes in the ST segment and T wave A : on admission, B : after 1 week, C : after 2 weeks, D : after 4 weeks, E : after 8 weeks. J Cardiol 2006 Jan; 47 1 : 39 46
3 No Reflow 41 LDH 268 IU/l CK 107 IU/l CK-MB 12IU/l T Fig. 1 : a L 1 5 ST R Reciprocal change Fig. 2 Chest radiograph on admission supine position revealing cardiomegaly and mild congestion Cardiothoracic ratio is 62%. X Fig. 2 : 62% Figs. 3 5 : SEQUOIA C256 Siemens Medical : transducer Acuson 7V3c modified Simpson 31% diastolic deceleration time : DDT 108 msec systolic retrograde flow : SRF Fig. 4 mean diastolic flow velocity: MDFV 25cm/sec peak diastolic flow velocity : PDFV 49cm/sec 150 g/kg/min 1.0 Fig. 6 : : Fig. 3 Echocardiographic findings on admission Apical four-chamber view at enddiastole left and endsystole right. J Cardiol 2006 Jan; 47 1 : 39 46
4 42 Fig. 4 Serial coronary flow velocity pattern by transthoracic Doppler echocardiography MDFV mean diastolic flow velocity; DDT diastolic deceleration time. 3 CK 107 IU/l Fig. 1 : 1 terminal T 2 T T 8 Figs. 4, 5, 7, 8 Table 2 : % 2 MDFV 16 cm/sec PDFV 31 cm/sec DDT 260 msec Fig Fig. 5 4 MDFV 17cm/sec PDFV 31 cm/sec DDT 373 msec SRF Fig. 4 8 MDFV 20 cm/sec PDFV 27cm/sec DDT 1,825 msec DDT SRF Fig. 4 2 Fig J Cardiol 2006 Jan; 47 1 : 39 46
5 No Reflow 43 Fig. 5 Coronary flow velocity reserve on admission upper and after 2 weeks lower CFVR coronary flow velocity reserve. Fig. 6 Emergency coronary angiograms No significant stenosis was detected in the right coronary artery, or left coronary artery. A : Right coronary artery, left anterior oblique view 50. B : Left coronary artery, right anterior oblique view 30. C: Left coronary artery, left anterior oblique view 50. J Cardiol 2006 Jan; 47 1 : 39 46
6 44 Fig. 7 Serial echocardiograms Left column: Apical four-chamber view at enddiastole upper and endsystole lower 2 weeks after admission. Right column: Apical four-chamber view at enddiastole upper and endsystole lower after 6 months. 2 DDT SRF no reflow 3 7 Yanagi 5 3 Kume cm/sec coronary flow velocity reserve : CFVR Hozumi 7 CFVR CFVR flow J Cardiol 2006 Jan; 47 1 : 39 46
7 No Reflow 45 Fig. 8 Serial echocardiograms showing transmitral flow pattern and deceleration time E/A early diastolic filling/left ventricular filling at atrial systole ; DcT deceleration time. Table 2 Serial echocardiographic findings Coronary flow velocity MDFV cm/sec PDFV cm/sec DDT msec Transmitral flow E m/sec A m/sec DcT m/sec On admission After 2 weeks After 4 weeks After 8 weeks , PDFV peak diastolic flow velocity. Other abbreviations as in Figs. 4, 8. good reflow 8,9 No reflow DDT SRF 9,10 no reflow no reflow DDT SRF DDT 600 msec SRF no reflow J Cardiol 2006 Jan; 47 1 : 39 46
8 46 80 a L 1 5 ST msec 4 6 no reflow J Cardiol 2006 Jan; 47 1 : Tsuchihashi K, Ueshima K, Uchida T, Oh-mura N, Kimura K, Owa M, Yoshiyama M, Miyazaki S, Haze K, Ogawa H, Honda T, Hase M, Kai R, Morii I, for the Angina Pectoris- Myocardial Infarction Investigations in Japan : Transient left ventricular apical ballooning without coronary artery stenosis : A novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol 2001 ; 38 : : ; 36: : : 2000 ; 48 : : Heart View 2004; 8 : Yanagi S, Nagae K, Yoshida K, Matsumura Y, Nagashima E, Okada M, Ota T, Hirota K, Yoshikawa J : Evaluation of coronary flow reserve using Doppler guide wire in patients with ampulla cardiomyopathy : Three case reports. J Cardiol 2002; 39 : in Jpn with Eng abstr 6 Kume T, Akasaka T, Kawamoto T, Watanabe N, Yoshitani H, Akiyama M, Koyama Y, Neishi Y, Tsukiji M, Yoshida K: Relationship between coronary flow reserve and recovery of regional left ventricular function in patients with takotsubo-like transient left ventricular dysfunction. J Cardiol 2004; 43 : in Jpn with Eng abstr 7 Hozumi T, Yoshida K, Akasaka T, Asami Y, Ogata Y, Takagi T, Kaji S, Kawamoto T, Ueda Y, Morioka S : Noninvasive assessment of coronary flow velocity and coronary flow velocity reserve in the left anterior descending coronary artery by Doppler echocardiography : Comparison with invasive technique. J Am Coll Cardiol 1998; 32 : Iwakura K, Ito H, Takiuchi S, Taniyama Y, Nakatsuchi Y, Negoro S, Higashino Y, Okamura A, Masuyama T, Hori M, Fujii K, Minamino T : Alternation in the coronary blood flow velocity pattern in patients with no reflow and reperfused acute myocardial infarction. Circulation 1996 ; 94 : Kawamoto T, Yoshida K, Akasaka T, Hozumi T, Takagi T, Kaji S, Ueda Y: Can coronary blood flow velocity pattern after primary percutaneous transluminal coronary angioplasty predict recovery of regional left ventricular function in patients with acute myocardial infarction? Circulation 1999; 100: : ; 35 : J Cardiol 2006 Jan; 47 1 : 39 46
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