The author reply: Recurrence of Different Types of Takotsubo Cardiomyopathy

摘要

I enjoyed very much reading the article by Amoran et al.,1) describing a 51-year-old woman who suffered takotsubo syndrome (TTS), triggered by severe cyclic vomiting syndrome (CVS) secondary to gastroparesis, which was followed by 3 recurrent TTS episodes emerging in 5, 14, and 19 months after the 1st index TTS episode, and with the 1st and 3rd recurrent TTS episodes triggered also by CVS. The patient developed her 4 TTS episodes showing sequentially the midventricular, apical, midventricular, and basal (or reverse or inverse) morphological left ventricular phenotypes. Incidentally the provided 4 movies are superior to the information provided by the corresponding still echocardiograms,1) and are particularly useful for patients suffering recurrent TTS. Repeated recurrent TTS episodes have been noted previously, and often tend to involve different myocardial territories.2) It is of interest that the 1st and 3rd TTS episodes of midventricular involvement were 14 months apart, perhaps providing the midventricular region time to recover from the consequent to the 1st episode myocardial denervation, and thus show the same response to the elevated catecholamines as the 1st episode. A few things needed to be explored in recurrent TTS are: 1) electrocardiograms occasionally show preferential changes in leads 1 and aVL, precordial leads, and upright T-waves in precordial leads, in the midventricular, apical, and basal, TTS phenotypes, correspondingly; 2) levels of blood borne catecholamines3) in the different TTS phenotypes; 3) levels of peak troponins in the different TTS phenotypes; 4) extent of the reduction of left ventricular ejection fraction in the different TTS phenotypes; 5) monitoring thoracic sympathetic nerve activity signals, a surrogate of stellate ganglia activity, in conjunction with the different TTS phenotypes4); 6) assessment of the regionality of myocardial edema, evaluated by cardiac magnetic resonance imaging, associated with different TTS phenotypes5); and 7) 123I-metaiodobenzylguanidine myocardial scintigraphy to document transient cardiac autonomic sympathetic denervation and its course5), associated with different TTS phenotypes.