LETTER TO THE EDITOR
Transient left ventricular apical ballooning without coronary artery stenosis: a form of stunning-like phenomenon? Reply
Kazufumi Tsuchihashi, MD, PhDa
a Second Department of Internal Medicine, Sapporo Medical University School of Medicine, S-1, W-16, Chuo-ku, Sapporo 060-0061, Japan
tsuchiha{at}sapmed.ac.jp
We appreciate the interest shown and the comment given by Ako et al. in regard to our recent clinical study (1) on a heart syndrome with transient left ventricular (LV) apical ballooning without coronary artery stenosis mimicking acute myocardial infarction. As mentioned in my study and others (2,3), coronary vasospasm under various physical and mental stresses, including administration of adrenergic drugs, might be considered as an initial etiological basis of this novel syndrome. Impaired coronary microcirculation in this syndrome was shown by Ako et al. (4) using an intracoronary Doppler flow-wire technique. The possibility of transient ischemia including microvessel vasospasm as an initiating factor of this syndrome could not be ruled out; however, we speculate that vasospasm is not the main cause, for the following several reasons. First, autopsy findings in some cases were different from those of myocardial ischemia (5). Second, impaired microcirculation during the follow-up period will not be direct evidence for considering the etiology of this syndrome, because the possibility of delayed recovery of impaired microcirculation due to transient wall motion abnormality is not excluded in this syndrome. Recent scintigraphic evaluation by Dr. Owa (co-author) showed a transient (but persistent for several months) perfusion–metabolism mismatch in the apex (6). Our study also showed a representative case with delayed recovery of coronary microcirculation (1).
Important etiological causes suspected from our study include stress cardiomyopathy caused by vigorous stress (cathecholamine exposure) (6–8), dynamic midventricular obstruction due to basal hypercontraction (9) and/or secondary myocardial ischemia caused by apical ballooning (increased wall tension). However, as already mentioned in the discussion (1), our study was a retrospective investigation and there are several limitations. Further cases, therefore, should be investigated to determine the pathogenesis of this heart syndrome.
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1. Tsuchihashi K, Ueshima K, Uchida T, et al. Transient left ventricular apical ballooning without coronary artery stenosis: a novel heart syndrome mimicking acute myocardial infarction. J Am Coll Cardiol. 2001;38:11–18[Abstract/Free Full Text]
2. Satoh H, Tateishi H, Uchida T, et al. Stunned myocardium with specific (tsubo-type) left ventriculographic configuration due to multivessel spasm. Kodama K, Haze K, Hori M. Clinical Aspect of Myocardial Injury: From Ischemia to Heart Failure. Tokyo: Kagakuhyouronsya; 1990. p. 56–64 [in Japanese]
3. Dote K, Sato H, Tateishi H, et al. Myocardial stunning due to simultaneous multivessel spasms: a review of 5 cases. [in Japanese with English abstract]J Cardiol. 1991;21:203–214[Medline]
4. Ako J, Takenaka K, Uno K, et al. Reversible left ventricular systolic dysfunction—reversibility of coronary microvascular abnormality. Jpn Heart J. 2001;42:355–363[CrossRef][Medline]
5. Kawai S, Suzuki H, Yamaguchi H, et al. Ampulla cardiomyopathy (‘Takotsubo’ cardiomyopathy)—reversible left ventricular dysfunction: with ST-segment elevation. Jpn Circ J. 2000;64:156–159[CrossRef][Medline]
6. Owa M, Aizawa K, Urasawa N, et al. Emotional stress-induced ampulla cardiomyopathy: discrepancy between metabolic and sympathetic innervation imaging performed during the recovery course. Jpn Circ J. 2001;65:349–352[CrossRef][Medline]
7. Pavin D, Le Breton H, Daubert C. Human stress cardiomyopathy mimicking acute myocardial syndrome. Heart. 1997;78:509–511[Abstract/Free Full Text]
8. Sharkey SW, Shear W, Hodges M, Herzog CA. Reversible myocardial contraction abnormalities in patients with an acute noncardiac illness. Chest. 1998;114:98–105[Abstract/Free Full Text]
9. Villareal RP, Achari A, Wilansky S, Wilson JM. Anteroapical stunning and left ventricular outflow tract obstruction. Mayo Clin Proc. 2001;76:79–83[Abstract]
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References