Letter to the Editor Inverted stress (Takotsubo) cardiomyopathy following Caesarean section: Insights from cardiac magnetic resonance Golmehr Ashrafpoor a, ⁎, Etienne Puymirat b , Laurent Sabbah c , Eric Bruguière a , Arshid Azarine a , Elie Mousseaux a, d , Alban Redheuil a, d a Cardiovascular Imaging Department, AP-HP, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France b Division of Cardiology, AP-HP, Hôpital Européen Georges Pompidou, Université Paris Descartes, Paris, France c Division of Cardiology, AP-HP, Hôpital Necker-Enfants Malades, Université Paris Descartes, Paris, France d INSERM U678, Université Pierre et Marie Curie, Paris, France article info Article history: Received 14 October 2012 Accepted 29 October 2012 Available online 22 November 2012 Keywords: Inverted stress cardiomyopathy Caesarean section Cardiovascular magnetic resonance Stress cardiomyopathy (SC) is an acute, reversible form of left ven- tricular (LV) systolic dysfunction with a suggestive contraction pattern in the absence of significant coronary lesions [1]. While there is apical ballooning in the majority of cases, a small proportion of patients pres- ent with basal dysfunction also called “inverted Takotsubo” [2,3]. SC is triggered by emotional or physical stress, including Caesarean sec- tion [4]. Furthermore, the usefulness of cardiac magnetic resonance (CMR) in SC has been reported [1]. A 34-year old female without past medical history was referred for new onset dyspnoea and transient atypical chest pain 5 h after an uncomplicated Caesarean section for a twin pregnancy at 37 weeks of amenorrhea. At admission, the patient presented signs of acute heart failure. The heart rate was 90 bpm and the blood pressure was 112/75 mm Hg. The ECG showed sinus rhythm and no signs of ische- mia. The blood tests revealed an elevation of troponin Ic (2.97 μg/l) and brain natriuretic peptide (1166 ng/ml). Transthoracic echocardiog- raphy described a non-dilated left ventricle with diffuse basal akinesia and severe systolic dysfunction. ECG-gated thoracic computed tomog- raphy ruled out pulmonary embolism, coronary dissection or obstruc- tion as well as an acute aortic syndrome and confirmed signs of pulmonary oedema. CMR showed upper-limit LV volumes and normal LV mass. LV ejec- tion fraction was 36%. Cine imaging showed circumferential akinesia of the base and mid-LV and normal apical contraction (Fig. 1 and Video). T2 spin-echo images displayed no significant abnormalities. Myocardial perfusion was remarkable for decreased circumferential basal and mid-LV perfusion whereas most of the apex, with the exception of the inferior segment, had normal to increased perfusion. However, there was no myocardial late gadolinium enhancement (LGE). There were mild pericardial and pleural effusions. The patient's evolution was favourable without any adverse events under conventional medical therapy. Control CMR at 3 months demon- strated a complete recovery of myocardial contraction. LV ejection frac- tion was 60% and T2, perfusion and LGE images were normal. As opposed to the classical form of SC, which primarily affects post- menopausal women, the inverted variant of SC occurs essentially in younger females, with a higher prevalence of identifiable triggering stress, and possibly in relation to a larger distribution of adrenergic re- ceptors in the basal segments in this population [3]. These patients seem to be less symptomatic and have fewer ECG anomalies [2]. While the apical form of SC has previously been reported after a Caesarean sec- tion, especially following the use of drugs such as catecholamines, pros- taglandins and oxytocin, the basal or inverted presentation is a rare presentation in this instance [4]. Differential diagnosis in this setting in- cludes peripartum cardiomyopathy (PPCM), which differs from typical SC by presentation and outcome. Indeed, PPCM does not present with a remarkable contraction pattern. Furthermore, recovery is only present in b 50% of patients, and may be delayed for several months. Finally, LGE can be present and is associated with worse prognosis [5]. The usefulness of CMR in stress cardiomyopathy has been recently underlined in a series of 256 patients [1]. However, the usefulness of first pass perfusion imaging has not been documented in this setting. In the present case of acute onset heart failure, CMR demonstrated re- versible inverted contraction and corresponding pattern of altered myocardial perfusion. However, no T2 hyperintensity or LGE was seen neither in the acute phase nor on follow-up. These findings to- gether with the non-coronary distribution of the contraction anoma- lies were against the hypothesis of a coronary plaque rupture or dissection. However, the presence of decreased basal perfusion in the akinetic region and normal to increased perfusion in the hyperki- netic apex later normalized on the follow-up study was in favour of the existence of transient myocardial ischemia and stunning in the absence of coronary artery disease. This hypothesis, probably related International Journal of Cardiology 165 (2013) e38–e39 ⁎ Corresponding author at: Hôpital Européen Georges Pompidou, Department of Cardiovascular Imaging, 20 rue Leblanc, 75015 Paris, France. Tel.: +33 1 56 09 38 24; fax: +33 1 56 09 54 91. E-mail address: golmehr@yahoo.com (G. Ashrafpoor). 0167-5273/$ – see front matter © 2012 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2012.10.087 Contents lists available at SciVerse ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard