European Heart Journal Advance Access originally published online on February 27, 2008
European Heart Journal 2008 29(8):1072; doi:10.1093/eurheartj/ehn064
Pathophysiology of ‘Tako-Tsubo’ cardiomyopathy: collecting pieces of a puzzle
Department of Cardiology, Angiology, and Intensive Care Medicine
Universitätsklinikum Schleswig-Holstein
Campus Lübeck
Ratzeburger Allee 160
D-23538 Lübeck
Germany
Department of Cardiology, Angiology, and Intensive Care Medicine
Universitätsklinikum Schleswig-Holstein
Campus Lübeck
Ratzeburger Allee 160
D-23538 Lübeck
Germany
Department of Cardiology, Angiology, and Intensive Care Medicine
Universitätsklinikum Schleswig-Holstein
Campus Lübeck
Ratzeburger Allee 160
D-23538 Lübeck
Germany
Tel: +494515002421
Fax: +494515002363
Email: peter.radke{at}uk-sh.de
It was with great interest that we read the paper of Yoshida et al.1 published in the November issue of this Journal. The authors who investigated patients with Tako-Tsubo cardiomyopathy (TTC) using F-18 fluorodeoxyglucose positron emission tomography (FDG-PET) report a profound impairment of glucose uptake in the apical left ventricular region, whereas 201Thallium single-photon emission computed tomography revealed only a slight reduction in myocardial perfusion.
As one of the limitations of their study, the authors state that variant forms of TTC such as mid-ventricular ballooning were not investigated, and that further research into the pathophysiology of these variant forms is required. Only recently, we also have published nuclear imaging data in 17 TTC patients by means of myocardial perfusion scintigraphy and FDG-PET and found patterns very similar to those of Yoshida et al.2 In addition to patients with the ‘typical’ appearance of TTC (apical ballooning) we were also able to identify patients with a mid-ventricular wall motion abnormality (atypical). In those subjects, as well as in patients with a ‘typical’ pattern of wall motion abnormalities, a decrease in glucose uptake and – to a lesser extent – a decrease in myocardial perfusion were closely correlated. The paper of Yoshida et al. and our study, therefore, confirm observations from recent case reports strongly suggesting that this ‘inverse perfusion–metabolism mismatch’, which has previously been described as ‘myocardial stunning’, characterizes an important and potentially central pathophysiologic feature of TTC.
Until now, an attempt to define TTC has been based on the morphology of left ventricular (apical) dysfunction, ECG changes, absence of significant coronary artery disease and disorders such as intracranial bleeding or pheochromocytoma (proposed Mayo criteria).3 Although temporary structural changes are related to TTC,4 the transient functional impairment of different regions of the left ventricle, occasionally also involving the right heart,5 is pivotal to the syndrome. Future attempts to define TTC should consider the evidence of uniform pathophysiologic findings such as prolongated myocardial stunning in rather different myocardial segments.
References
- Yoshida T, Hibino T, Kako N, Murai S, Oguri M, Kato K, Yajima K, Ohte N, Yokoi K, Kimura G. A pathophysiologic study of tako-tsubo cardiomyopathy with F-18 fluorodeoxyglucose positron emission tomography. Eur Heart J (2007) 28:2598–2604.
[Abstract/Free Full Text] - Kurowski V, Kaiser A, von Hof K, Killermann DP, Mayer B, Hartmann F, Schunkert H, Radke PW. Apical and midventricular transient left ventricular dysfunction syndrome ("Tako-Tsubo" Cardiomyopathy): frequency, mechanisms and prognosis. Chest (2007) 132:809–816.[CrossRef][Web of Science][Medline]
- Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, Rihal CS. Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction. Ann Intern Med (2004) 141:858–865.
[Abstract/Free Full Text] - Nef HM, Möllmann H, Kostin S, Troidl C, Voss S, Weber M, Dill T, Rolf A, Brandt R, Hamm CW, Elsässer A. Tako-Tsubo cardiomyopathy: intraindividual structural analysis in the acute phase and after functional recovery. Eur Heart J (2007) 28:2456–2464.
[Abstract/Free Full Text] - Haghi D, Athanasiadis A, Papavassiliu T, Suselbeck T, Fluechter S, Mahrholdt H, Borggrefe M, Sechtem U. Right ventricular involvement in Takotsubo cardiomyopathy. Eur Heart J (2006) 27:2433–2439.
[Abstract/Free Full Text]
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