Documentation of Focal Takotsubo Syndrome and Its Diagnostic Implications

To the Editor:

It was refreshing to read the paper by Kato et al recently published in the Journal,¹ about focal takotsubo syndrome (TTS) in 10 patients out of a total of 144 patients, 85 of whom had apical TTS, and 49 who had the mid-ventricular TTS variants. The authors, who have previously published on the focal type of TTS,² as have some other workers,^3,4 emphasized the difficulties of differentiating the focal variety of TTS from an aborted acute myocardial infarction (MI) in the absence of underlying coronary artery disease (CAD).¹ It is not surprising that the mean left ventricular ejection fraction (LVEF) of the patients with focal TTS was higher than in those with the other 2 variants of TTS,¹ considering that the focal variant reflected a smaller myocardial territory transiently involved with the disease. It would have been informative if the authors had provided levels of troponin rise (measured in 137 patients) in the 3 different variant TTS groups, to explore whether the focal TTS patients had the lowest troponin rise, which would parallel their highest LVEF.

The authors were very careful in defining focal TTS, and distinguishing it from aborted MI in the absence of obstructive CAD or severe spasm, and stressed the importance of using biplane left ventriculography, or in its absence, cardiac magnetic resonance imaging, or single-photon emission computed tomography, using ¹²³I-metaiodobenzylguanidine or ¹²³I-β-methyl iodophenyl pentadecanoic acid.¹ However, they admitted that “there may be patients with focal TTS who have regional wall motion abnormality only in the anterolateral segment or the basal-septal segment” and that “focal TTS might be observed in other segments”,¹ and in this respect querying their catheterization database, searching for focal TTS in other territories, may be enlightening. Also, the authors found that focal TTS is not rare,¹ and this phenotype may be an atypical or milder form of TTS.^5,6

Finally, one wonders whether focal TTS could be present as a “comorbidity phenotype”, or “TTS component” in patients with an acute MI, involving the myocardial territory contralateral to the MI,^5,6 and in this respect the authors could further their concept of focal TTS by querying their database of patients with obstructive CAD and acute MI. Indeed, such patients exist and relevant cases have been published.^7–9

Conflict of Interest

There is nothing to disclose that could be construed as a conflict of interest in connection with the submission of this letter.

• John E. Madias, MD
• Icahn School of Medicine at Mount Sinai, New York, NY;
• The Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, USA

(Released online July 26, 2016)

References

• 1.    Kato  K,  Kitahara  H,  Fujimoto  Y,  Sakai  Y,  Ishibashi  I,  Himi  T, et al. Prevalence and clinical features of focal Takotsubo cardiomyopathy. Circ J 2016; 80: 1824–1829.
• 2.    Kato  K,  Sakai  Y,  Ishibashi  I,  Kobayashi  Y. Transient focal left ventricular ballooning: A new variant of Takotsubo cardiomyopathy. Eur Heart J Cardiovasc Imaging 2015; 16: 1406.
• 3.    Zbinden  R,  Mutter  M,  Weishaupt  D. Cardiac magnetic resonance imaging in the diagnosis of anterolateral left ventricular ballooning, a variant of classic takotsubo cardiomyopathy. Case Rep Cardiol 2012; 2012: 537169.
• 4.    Demirelli  S,  Ermis  E,  Hatem  E,  Uslu  A,  Askin  L. Focal mid-ventricular anterior ballooning: An unusual pattern of Takotsubo cardiomyopathy. Intractable Rare Dis Res 2015; 4: 108–110.
• 5.    Madias  JE. Forme fruste cases of Takotsubo syndrome: A hypothesis. Eur J Intern Med 2014; 25: e47, doi:10.1016/j.ejim.2014.01.002.
• 6.    Madias  JE. Why the current diagnostic criteria of Takotsubo syndrome are outmoded: A proposal for new criteria. Int J Cardiol 2014; 174: 468–470.
• 7.    Tota  F,  Ruggiero  M,  Sassara  M,  Locuratolo  N,  Sublimi Saponetti  L,  Frasso  G, et al. Subacute stent thrombosis and stress-induced cardiomyopathy: Trigger or consequence? Am J Cardiovasc Dis 2013; 3: 175–179.
• 8.    Showkathali  R,  Patel  H,  Ramoutar  A,  Kabir  AM,  Sayer  JW,  Clesham  GJ, et al. Typical takotsubo cardiomyopathy in suspected ST elevation myocardial infarction patients admitted for primary percutaneous coronary intervention. Eur J Intern Med 2014; 25: 132–136.
• 9.    Crimizade  U,  Messas  N,  Blondet  C,  Jesel  L,  Duculescu  E,  Ohlmann  P, et al. Biventricular Takotsubo cardiomyopathy triggered by myocardial ischemic injury: Insights from multimodal imaging approach. Int J Cardiol 2016; 207: 104–106.