From the Guidelines
Dyskinesia in the left ventricular (LV) apex seen on transthoracic echocardiography (TTE) is most commonly caused by Takotsubo cardiomyopathy, myocardial infarction, and apical hypertrophic cardiomyopathy, with Takotsubo cardiomyopathy being a key consideration due to its transient nature and potential for resolution within weeks 1.
Causes of Dyskinesia
- Myocardial infarction, particularly involving the left anterior descending artery, resulting in scarring and impaired contractility of the apical myocardium
- Takotsubo cardiomyopathy, also known as stress-induced cardiomyopathy, presenting with transient apical ballooning and dyskinesia following emotional or physical stress
- Apical hypertrophic cardiomyopathy causing dyskinetic motion due to the thickened apical myocardium
- Other less common causes include myocarditis, cardiac sarcoidosis, and cardiac amyloidosis affecting the apex
- Iatrogenic causes such as post-cardiac surgery or ablation procedures may also result in apical dyskinesia
Diagnostic Considerations
When evaluating apical dyskinesia on TTE, it's essential to assess for wall thinning, aneurysm formation, and thrombus, which may influence management decisions regarding anticoagulation therapy. Correlation with clinical history, electrocardiogram findings, and cardiac biomarkers is crucial for accurate diagnosis and appropriate treatment planning, as emphasized in recent guidelines 1. Advanced echocardiographic techniques, such as speckle-tracking imaging, can reveal paradoxical (dyskinetic) positive longitudinal systolic strain of biventricular mid-apical segments, aiding in the diagnosis of conditions like Takotsubo cardiomyopathy 1.
From the Research
Common Causes of Dyskinesia in the LV Apex Seen on TTE
- Coronary artery obstruction or disease, which can lead to left ventricular dyskinesis, especially in the right coronary artery 2
- Myocardial infarction, which can cause dyskinesis in the left ventricle, particularly in the apical region 2, 3
- Takotsubo syndrome, also known as transient apical dyskinesia syndrome, which is characterized by transient left ventricular apical ballooning and is often triggered by severe emotional stress 4, 5
- Pseudodyskinesis of the inferior left ventricular wall, which can be a mimic of myocardial infarction and is associated with preserved systolic wall thickening and extrinsic diastolic compression 3
- Other factors, such as the use of soft tissue displacement as a diagnostic marker, can also contribute to the detection of apical dyskinesis on TTE 6
Diagnostic Considerations
- The diagnosis of dyskinesia in the LV apex can be challenging, and it is essential to consider various diagnostic criteria and complementary examinations to accurately diagnose the condition 4
- The use of cardiac MRI can help validate the presence of apical dyskinesis and improve diagnostic accuracy 6
- Echocardiography can also be used to diagnose dyskinesia, but it is crucial to distinguish between true dyskinesis and pseudodyskinesis 3