More than the eye can see: Left ventricular global longitudinal strain assessment in a patient with takotsubo cardiomyopathy within a 9-month follow-up

Sonia J Konsek-Komorowska, Piotr Cygański, Andrzej Rynkiewicz

Department of Cardiology and Internal Medicine, School of Medicine, Collegium Medicum, University of Warmia and Mazury in Olsztyn, Olsztyn, Poland

Correspondence to:

Sonia J Konsek-Komorowska,

Department of Cardiology and Internal Medicine,

School of Medicine,

Collegium Medicum,

University of Warmia and Mazury in Olsztyn

Aleja Warszawska 30, 10–082 Olsztyn, Poland,

phone: +48 89 524 53 89,

e-mail: sonia.konsek@interia.pl

Copyright by the Author(s), 2021

Kardiol Pol. 2021; 79 (7–8): 887–888; DOI: 10.33963/KP.a2021.0018

Received: April 28, 2021

Revision accepted: May 23, 2021

Published online: May 24, 2021


Takotsubo cardiomyopathy (TTC) is a cardiac condition characterized by acute but reversible left ventricular (LV) dysfunction in the absence of obstructive coronary artery disease [13]. Two-dimensional (2D) speckle-tracking echocardiography (STE) is a useful method for evaluating global and regional left ventricular function and is consistently more sensitive than conventional echocardiography in detecting minor myocardial abnormalities [1]. The utility of STE in TTC patients has been described in a few short-term reports [14], however, there is limited understanding around the time course of functional recovery in TTC patients [1]. In this article, we present a case of a 30-year-old female with a sequential evaluation of global longitudinal strain (GLS) during a 9-month follow-up.

The patient with a history of supraventricular tachycardia was admitted to the hospital with chest pain radiating to the left arm. An electrocardiogram showed sinus rhythm with T wave inversion and QT prolongation. High-sensitivity troponin T and the concentration of N-terminal brain natriuretic propeptide were moderately elevated. Transthoracic echocardiography (TTE) revealed hypokinesis/akinesis of new apical segments and the apex. Compared to a routine TTE performed 4 months before the admission to the hospital, LV ejection fraction (LVEF) decreased from 70% to 50%. 2D STE analysis showed a severe decline in longitudinal strain (LS) within all apical segments and the apex, as well as a mild decline within mid-cavity segments, with reduced GLS from 26.9% to 18.7% (Figure 1AB).


Figure 1. GLS assessment. A. Sequential evaluation of GLS from baseline (4 months before diagnosis of TTC) through and during 9 months follow-up. B. The day of hospital admission severe segmental decline in longitudinal strain within all apical segments and apex, with the concomitant mild decline within mid-cavity segments. C. 5th day of hospitalization a progressive segmental decline of longitudinal strain within mid-cavity and basal segments of the inferolateral wall with a slight improvement in all apical segments and apex. D. 15th day of hospitalization improvement in longitudinal strain within the apical segments, apex, and mid-cavity segments, excluding mid-cavity segments of the anterolateral and inferolateral wall. E. 5 months after hospital admission continuous slight improvement in longitudinal strain within all previously impaired segments. F. 9 months after admission to the hospital full improvement in longitudinal strain within all segments compared to baseline

Abbreviations: GLS, global longitudinal strain; TTC, takotsubo cardiomyopathy

Coronary angiography showed no abnormalities. Based on the patient’s clinical features, along with electrocardiogram and echocardiographic abnormalities in the absence of coronary lesions, a typical apical ballooning TTC was diagnosed. The patient was treated with zofenopril, propranolol, spironolactone, and atorvastatin for 9 months. Subsequent control TTEs were performed on the 5th and 15th day of hospitalization (Figure 1C and D), as well as at 5 (Figure 1E), and 9 months after admission to the hospital (Figure 1F) revealing progressive improvement to LV contractile function. LVEF returned to the normal range of 70% within 5 months (Supplementary material, Video S1) and a GLS of 25.9% within 9 months. Interestingly, the control 2D STE assessment revealed that although LS in apical segments had been impaired for just a short time (LS drop from 28.2% to 10%), mid-cavity and basal segments were also affected however to a lesser extent, but for a prolonged duration (LS drop from 28% to 19.2% and from 25.7% to 21.2%, respectively) (Figure 1A). Not all changes were easily noticeable in conventional 2D echocardiography and suggest a slow, gradually spreading process.

In our report, we describe a case of TTC with changing LV systolic function assessed by LVEF and GLS throughout the acute and subacute phases (lasting approximately 1 month) and gradual recovery to baseline over the following 8 months. Our report is consistent with other studies reporting the presence of subtle LV dysfunction, even after the normalization of LVEF [1, 3]. To our knowledge, this is the first case reported in the literature showing the long-term sequential evaluation of GLS in a TTC patient. Further analysis of correlation of segmental myocardial deformation using strain-encoded cardiac magnetic resonance imaging (SENC) and STE could be useful [5].

Supplementary material

Supplementary material is available at https://journals.viamedica.pl/kardiologia_polska.

Article information


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