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Takotsubo cardiomyopathy on echocardiography

A circumferential abnormality that crosses coronary territories (for example all apical segments) with hyperkinetic remaining segments. Variants: apical, mid-ventricular and reverse (basal).

Watch it in the simulator →Practise random cases

Where to look

Apical 4-, 2- and 3-chamber views together: the abnormality runs circumferentially across all walls at the same level.

Typical wall-motion pattern

Example: Takotsubo — apical ballooning

Akinetic: segments 7, 8, 12, 13, 14, 15, 16, 17 · Hypokinetic: mid inferoseptal, mid inferior, mid inferolateral

EF in this example: 43% (Impaired (36–49%)).

1 Normal2 Hypokinetic3 Akinetic4 Dyskinetic5 Aneurysmal

Ejection fraction

Across 24 simulated cases of this pattern the true EF ranged from 24% to 47% (median 41%, Impaired (36–49%)). Every case in the simulator is different, so practise until your visual estimate lands in the right 5% range.

Variants you will see

Takotsubo — apical ballooning
Takotsubo — mid-ventricular variant
Takotsubo — reverse (basal) variant

Teaching points

Takotsubo: a circumferential RWMA that extends beyond any single coronary territory, with hyperkinetic remaining segments. The pattern, not the territory, is the clue.
Atrial fibrillation: filling and EF vary from beat to beat. Average at least five beats, or use an index beat (one that follows two similar RR intervals), and avoid beats after a very short RR interval.
Ventricular ectopics: the premature beat is weak and dyssynchronous and the beat after the pause is stronger. Judge EF and wall motion on normal sinus beats only.

Common pitfalls

Do not force the pattern into a single coronary territory; look at the hyperkinetic base.

Try it now: open the Takotsubo (stress) cardiomyopathy example with the segment overlay, then test yourself in Practice where cases are random and graded against the exact answer.