Late Gadolinium Enhancement on Cardiac MRI in Patients With Takotsubo Syndrome: Insights From the Multicenter EVOLUTION Registry

Background: Late gadolinium enhancement (LGE) has traditionally been considered absent in Takotsubo syndrome (TS). However, accumulating evidence indicates the finding's presence during the acute phase in a subset of patients. Objectives: To evaluate the frequency of LGE, identify factors associated with LGE presence, assess prognostic implications of LGE, and compare methods for quantifying LGE extent, in patients with TS undergoing cardiac MRI. Methods: This retrospective study included 370 patients (338 female; 42 male; mean age 69.7±12 years) from the nine-center EVOLUTION registry from November 21, 2007 to December 22, 2024. The registry included patients with hospital admission for TS who underwent cardiac MRI within 10 days after symptom onset; patients were required to fulfill professional society criteria for TS diagnosis. Two radiologists independently reviewed LGE images to assess examinations for the visual presence of LGE, resolving discrepancies for further analyses. In patients with LGE, a radiologist quantified LGE extent visually and using semiautomated methods (2-SD, 3-SD, and 5-SD threshold methods relative to remote myocardial signal intensity; full-width at half-maximum method relative to LGE peak signal intensity). In-hospital adverse events (death or major cardiac or cerebrovascular events) were identified. Results: The two radiologists identified LGE in 58 (15.7%) and 54 (14.5%) patients; by consensus, LGE was present in 58 (15.7%) patients. In multivariable analysis, LGE presence was independently associated with a shorter interval from presentation to cardiac MRI (OR per day=0.81, p=.003) and a greater extent of myocardial edema on T2-weighted STIR images (OR per segment=1.44, p<.001). The mean LGE extent by visual assessment was 25.5%. Among semiautomated methods, correlation with visual assessment of LGE extent was greatest for the 2-SD threshold method (ρ=0.93). In-hospital adverse events occurred in 88 (23.8%) patients and were not significantly associated with LGE presence (p=.44) or extent by any method (all p>.05). Conclusion: LGE was identified in 15.7% of patients with TS and showed significant independent associations with greater myocardial edema extent and earlier MRI timing after presentation but was not associated with in-hospital adverse events. Clinical Impact: The results may provide useful context when radiologists encounter LGE on cardiac MRI in patients with TS.