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Reported Cases of Recurrent Takotsubo Cardiomyopathy with Variant Forms of Left Ventricular Dysfunction

      To the Editor:
      We read with great interest the article by Aggarwal and Krantz,
      • Aggarwal V.
      • Krantz M.J.
      Migratory takotsubo cardiomyopathy in the setting of cholecystitis.
      entitled “Migratory takotsubo cardiomyopathy in the setting of cholecystitis.” This was a very interesting case presentation regarding stress-related cardiomyopathy involving variable myocardial segments at different time points.
      The author mentioned that this was the first reported case. After careful review, however, we found several reports in the literature of recurrent takotsubo cardiomyopathy with variable patterns of left ventricular dysfunction. In 2007, Blessing et al
      • Blessing E.
      • Steen H.
      • Rosenberg M.
      • Katus H.
      • Frey N.
      Recurrence of takotsubo cardiomyopathy with variant forms of left ventricular dysfunction.
      reported a 70-year-old man with recurrent takotsubo cardiomyopathy demonstrating basal area akinesis initially and apical ballooning on the second episode. In 2009, Izumo et al
      • Izumo M.
      • Akashi Y.J.
      • Suzuki K.
      • Omiya K.
      • Miyake F.
      • Ohtaki E.
      Recurrent takotsubo cardiomyopathy with variant forms of left ventricular dysfunction.
      reported a 78-year-old male with recurrent takotsubo cardiomyopathy. At the first episode, the patient was found to have apical akinesis and basal hyperkinesis while at the second episode; 2 years later, he was found to have mid-ventricular akinesis combined with normal apical wall motion. In 2011, From et al
      • From A.M.
      • Sandhu G.S.
      • Nkomo V.T.
      • Prasad A.
      Apical ballooning syndrome (Takotsubo cardiomyopathy) presenting with typical left ventricular morphology at initial presentation and mid-ventricular variant during a recurrence.
      presented a clinical image of a 65-year-old female with recurrent takotsubo cardiomyopathy manifesting as typical apical ballooning at the first episode and mid-ventricular variant at the second episode 3 years later. In 2012, Ghadri et al
      • Ghadri J.R.
      • Jaguszewski M.
      • Corti R.
      • Lüscher T.F.
      • Templin C.
      Different wall motion patterns of three consecutive episodes of takotsubo cardiomyopathy in the same patient.
      reported a case of a 65-year-old female with 3 episodes of takotsubo cardiomyopathy involving different myocardial regions.
      According to these case reports, it may not be uncommon for recurrent takotsubo cardiomyopathy to involve different myocardial regions with each episode. Unfortunately, the mechanism of this variation is unclear at this time.

      References

        • Aggarwal V.
        • Krantz M.J.
        Migratory takotsubo cardiomyopathy in the setting of cholecystitis.
        Am J Med. 2012; 125: e5-e6
        • Blessing E.
        • Steen H.
        • Rosenberg M.
        • Katus H.
        • Frey N.
        Recurrence of takotsubo cardiomyopathy with variant forms of left ventricular dysfunction.
        J Am Soc Echocardiogr. 2007; 20: 439.e11-439.e12
        • Izumo M.
        • Akashi Y.J.
        • Suzuki K.
        • Omiya K.
        • Miyake F.
        • Ohtaki E.
        Recurrent takotsubo cardiomyopathy with variant forms of left ventricular dysfunction.
        J Cardiol Cases. 2010; 2: e37-e40
        • From A.M.
        • Sandhu G.S.
        • Nkomo V.T.
        • Prasad A.
        Apical ballooning syndrome (Takotsubo cardiomyopathy) presenting with typical left ventricular morphology at initial presentation and mid-ventricular variant during a recurrence.
        J Am Coll Cardiol. 2011; 58: e1
        • Ghadri J.R.
        • Jaguszewski M.
        • Corti R.
        • Lüscher T.F.
        • Templin C.
        Different wall motion patterns of three consecutive episodes of takotsubo cardiomyopathy in the same patient.
        Int J Cardiol. 2012; 160: e25-e27

      Linked Article

      • Migratory Takotsubo Cardiomyopathy in the Setting of Cholecystitis
        The American Journal of MedicineVol. 125Issue 12
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          Stress-related cardiomyopathy is a clinical disorder mimicking an acute coronary syndrome. It is defined by the presence of a focal reversible wall-motion abnormality and the absence of obstructive coronary artery disease.1 Stress-related cardiomyopathy often presents with transient “ballooning” of the left ventricular apex, the so-called takotsubo cardiomyopathy. However, involvement of multiple myocardial regions has never been described. We report a case of stress-related cardiomyopathy associated with cholecystitis, sequentially involving different myocardial territories and resolving after cholecystectomy.
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      • The Reply
        The American Journal of MedicineVol. 126Issue 7
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          We thank Ratanapo et al1 for their insightful comments regarding migratory takotsubo. They correctly highlight previous isolated reports of stress cardiomyopathy involving variable myocardial segments at different time points. We should have been clearer in distinguishing our report as the first description of this phenomenon in the setting of an “indolent” stressor, in this case cholecystitis. In addition, our patient developed flash pulmonary edema on her third presentation, presumably related to diastolic dysfunction given no evidence of segmental wall motion abnormalities or a reduction in ejection fraction.
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