Perfusion
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Dynamic left ventricular outflow tract obstruction in Takotsubo syndrome: is it primary, secondary or both? John E Madias Perfusion published online 16 October 2014 DOI: 10.1177/0267659114557185 The online version of this article can be found at: http://prf.sagepub.com/content/early/2014/10/16/0267659114557185
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557185 research-article2014
PRF0010.1177/0267659114557185PerfusionMadias
Letter to the Editor
Dynamic left ventricular outflow tract obstruction in Takotsubo syndrome: is it primary, secondary or both?
Perfusion 1 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114557185 prf.sagepub.com
John E Madias
Sir, The article by Liang et al., published ahead of print in the May 21, 2014 issue of the Perfusion1 about a patient who suffered recurrent Takotsubo syndrome (TTS), a 73-year-old woman with basal hyperkinesis (BH), mitral regurgitation (MR), apical ballooning (AB), hypotension and successful management with judicious administration of fluids and beta blockers (BB), brings forth again the issues of the mechanism of BH and MR in TTS. Many cases of TTS with BH and MR have been published,2 but the pathophysiologic mechanisms and natural course of these phenomena in patients with TTS continue to be elusive. The authors state that the “dynamic left ventricular outflow obstruction” noted in their patient was “ due to systolic anterior motion of the mitral valve leaflet and secondary functional mitral regurgitation”, but it may be more plausible to consider the BH to be the cause of the systolic anterior motion of the mitral valve leaflet, causing, of course, further tract obstruction. What the sequence is in the interplay of the AB and BH in TTS is still unknown: specifically, is the AB followed by BH as a compensatory response, akin to the one seen in the setting of acute myocardial infarction, where hyperdymamic function of the contralateral region is found to the infarcted myocardial territory, which displays akinesis and/or dyskinesis, or is BH a primary effect of TTS,3 causing or contributing to the AB? Also, one should include the possibility that TTS is characterized by BH and AB, which appear simultaneously as “part and parcel” of this disease entity. Other plausible pathophysiologic sequences include a dynamic course of both BH and AB over the course of the illness or the possibility that, initially, BH ensues (primary), which causes or exacerbates the AB, while later in the process, the enhanced AB and the resultant hypotension and hemodynamic deterioration lead to further BH (secondary).3 Descriptions of what we find in patients with TTS by cross-sectional imaging at the acute point and the time of discharge or later follow-up are not expected to provide an answer to the above questions.
What is needed is frequent serial implementation of echocardiography during hospitalization,4 particularly in patients with TTS presenting to the hospital shortly after inception of their symptoms or who suffer TTS after being admitted for other illnesses, surgery or diagnostic or therapeutic procedures. Declaration of Conflicting Interest The authors declare that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Liang J, Janish C, Bishu K, Reeder G. Dynamic left ventricular outflow tract obstruction in apical ballooning syndrome (Takotsubo cardiomyopathy). Perfusion 2014 Epub, DOI: 10.1177/0267659114536584. 2. http://www.ncbi.nlm.nih.gov/pubmed/?term=takotsubo (accessed last on 6/21/14). 3. Madias JE. A proposal for a pathogenesis-seeking animal model of Takotsubo syndrome. Am J Cardiol 2013; 111: 1231–1232. 4. Madias JE. Appropriate implementation of echocardiography in Takotsubo syndrome: earlier and more frequently. Echocardiography 2013; 30: 1123–1125.
Icahn School of Medicine at Mount Sinai, New York, NY and the Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, USA Corresponding author: John E Madias Division of Cardiology Elmhurst Hospital Center 79-01 Broadway Elmhurst NY 11373 USA. Email: [email protected]
Downloaded from prf.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 8, 2014
http://prf.sagepub.com/
Dynamic left ventricular outflow tract obstruction in Takotsubo syndrome: is it primary, secondary or both? John E Madias Perfusion published online 16 October 2014 DOI: 10.1177/0267659114557185 The online version of this article can be found at: http://prf.sagepub.com/content/early/2014/10/16/0267659114557185
Published by: http://www.sagepublications.com
Additional services and information for Perfusion can be found at: Email Alerts: http://prf.sagepub.com/cgi/alerts Subscriptions: http://prf.sagepub.com/subscriptions Reprints: http://www.sagepub.com/journalsReprints.nav Permissions: http://www.sagepub.com/journalsPermissions.nav
>> OnlineFirst Version of Record - Oct 16, 2014 What is This?
Downloaded from prf.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 8, 2014
557185 research-article2014
PRF0010.1177/0267659114557185PerfusionMadias
Letter to the Editor
Dynamic left ventricular outflow tract obstruction in Takotsubo syndrome: is it primary, secondary or both?
Perfusion 1 © The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0267659114557185 prf.sagepub.com
John E Madias
Sir, The article by Liang et al., published ahead of print in the May 21, 2014 issue of the Perfusion1 about a patient who suffered recurrent Takotsubo syndrome (TTS), a 73-year-old woman with basal hyperkinesis (BH), mitral regurgitation (MR), apical ballooning (AB), hypotension and successful management with judicious administration of fluids and beta blockers (BB), brings forth again the issues of the mechanism of BH and MR in TTS. Many cases of TTS with BH and MR have been published,2 but the pathophysiologic mechanisms and natural course of these phenomena in patients with TTS continue to be elusive. The authors state that the “dynamic left ventricular outflow obstruction” noted in their patient was “ due to systolic anterior motion of the mitral valve leaflet and secondary functional mitral regurgitation”, but it may be more plausible to consider the BH to be the cause of the systolic anterior motion of the mitral valve leaflet, causing, of course, further tract obstruction. What the sequence is in the interplay of the AB and BH in TTS is still unknown: specifically, is the AB followed by BH as a compensatory response, akin to the one seen in the setting of acute myocardial infarction, where hyperdymamic function of the contralateral region is found to the infarcted myocardial territory, which displays akinesis and/or dyskinesis, or is BH a primary effect of TTS,3 causing or contributing to the AB? Also, one should include the possibility that TTS is characterized by BH and AB, which appear simultaneously as “part and parcel” of this disease entity. Other plausible pathophysiologic sequences include a dynamic course of both BH and AB over the course of the illness or the possibility that, initially, BH ensues (primary), which causes or exacerbates the AB, while later in the process, the enhanced AB and the resultant hypotension and hemodynamic deterioration lead to further BH (secondary).3 Descriptions of what we find in patients with TTS by cross-sectional imaging at the acute point and the time of discharge or later follow-up are not expected to provide an answer to the above questions.
What is needed is frequent serial implementation of echocardiography during hospitalization,4 particularly in patients with TTS presenting to the hospital shortly after inception of their symptoms or who suffer TTS after being admitted for other illnesses, surgery or diagnostic or therapeutic procedures. Declaration of Conflicting Interest The authors declare that there is no conflict of interest.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. Liang J, Janish C, Bishu K, Reeder G. Dynamic left ventricular outflow tract obstruction in apical ballooning syndrome (Takotsubo cardiomyopathy). Perfusion 2014 Epub, DOI: 10.1177/0267659114536584. 2. http://www.ncbi.nlm.nih.gov/pubmed/?term=takotsubo (accessed last on 6/21/14). 3. Madias JE. A proposal for a pathogenesis-seeking animal model of Takotsubo syndrome. Am J Cardiol 2013; 111: 1231–1232. 4. Madias JE. Appropriate implementation of echocardiography in Takotsubo syndrome: earlier and more frequently. Echocardiography 2013; 30: 1123–1125.
Icahn School of Medicine at Mount Sinai, New York, NY and the Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, USA Corresponding author: John E Madias Division of Cardiology Elmhurst Hospital Center 79-01 Broadway Elmhurst NY 11373 USA. Email: [email protected]
Downloaded from prf.sagepub.com at TEXAS SOUTHERN UNIVERSITY on November 8, 2014
