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J Am Soc Echocardiogr. 2014 Jan;27(1):101-6. doi: 10.1016/j.echo.2013.09.001. Epub 2013 Oct 9.

Right ventricular myocardial performance index derived from tissue Doppler echocardiography is useful in differentiating apical ballooning syndrome from cardiomyopathy due to left anterior descending coronary artery disease.

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Heart and Vascular Center, Division of Cardiology, MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio.
Heart and Vascular Center, Division of Cardiology, MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio. Electronic address:



Apical ballooning syndrome (ABS) and obstructive coronary artery disease of the left anterior descending coronary artery (LAD) can both result in similar left ventricular apical wall motion abnormalities. The right ventricle may more likely be involved in ABS, and its careful evaluation may help differentiate the two conditions. Therefore, the aim of this study was to determine the roles of echocardiographic measures of right ventricular (RV) function, namely, Doppler tissue imaging-derived RV index of myocardial performance (RIMP), RV basal free wall systolic excursion velocity (RV S'), and tricuspid annular plane systolic excursion, in differentiating ABS from obstructive LAD disease.


A total of 80 patients with new extensive apical left ventricular wall motion abnormalities on echocardiography who underwent coronary angiography were identified retrospectively. Patients with insufficient echocardiographic data were excluded (n = 17). Admission clinical and echocardiographic data were compared between patients with obstructive disease of the LAD (LAD group; n = 46) and those with normal coronary arteries (ABS group; n = 17).


The ABS group had significantly greater RIMP (1.03 ± 0.22 vs 0.44 ± 0.18, P < .001). In predicting ABS, RIMP > 0.74 had sensitivity of 94%, specificity of 94%, positive predictive value of 84%, and negative predictive value of 98%, with excellent discriminatory ability (area under the receiver operating characteristic curve, 0.96 ± 0.03). Other measures of RV function (i.e., tricuspid annular plane systolic excursion and RV S') were similar between the two groups.


Doppler tissue imaging-derived RIMP may help differentiate ABS from obstructive LAD disease with high accuracy. This easily obtainable measurement may offer a noninvasive tool to differentiate these two conditions.


2D; ABS; Apical ballooning syndrome; Coronary artery disease; Doppler tissue imaging; ET; ICC; Intraclass correlation coefficient; LAD; Left anterior descending coronary artery; RIMP; ROC; RV; Receiver operating characteristic; Right ventricular; Right ventricular ejection time; Right ventricular index of myocardial performance; Right ventricular myocardial performance index; Stress cardiomyopathy; TAPSE; Takotsubo cardiomyopathy; Tricuspid annular plane systolic excursion; Two-dimensional

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