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This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Probal K. Ghosh Alexander Kogan Ehud Raanani Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Ghosh, P. K. Articles by Raanani, E. PubMed Articles by Ghosh, P. K. Articles by Raanani, E. Related Collections Cardiac - other Valve disease

Letters to the Editor

Mitral valve replacement and Takotsubo syndrome

Department of Cardiothoracic Surgery, The Chaim Sheba Medical Center, Tel HaShomer 52621, Israel

Received 18 March 2008; accepted 22 April 2008.

^_* Corresponding author. Tel.: +972 3 530 4586; fax: +972 3 530 2410. (Email: probal1945{at}yahoo.com).

Key Words: Mitral valve replacement • Chordal preservation • Takotsubo syndrome

Athanasiou et al. [1] should be commended for their seminal review on evidence synthesis and critical reappraisal of surgical techniques of preservation of mitral subvalvar apparatus. However, when Lillehei and colleagues in the early 1960s had proposed the chordal-sparing technique of mitral valve replacement (MVR), the entity of Takotsubo syndrome had not been described. Nearly 30 years later, Satoh et al. [2], Dote and colleagues [3] from Japan described in 1990 and 1991 this novel syndrome, characterized by transient reversible left ventricular (LV) dysfunction in the absence of coronary artery disease, with chest pain, electrocardiographic changes mimicking acute anterior myocardial infarction, but only minimal release of myocardial enzymes. Left ventriculograms revealed a peculiar shape of the LV resembling a Takotsubo [the type of bottle with a round bottom and narrow neck – used in Japan for trapping octopus]. The syndrome is also known as acute left ventricular ballooning, transient apical ballooning, ampulla cardiomyopathy and because stress has been implicated in its pathophysiology. Human stress cardiomyopathy or broken-heart syndrome.

We have earlier described the occurrence of Takotsubo syndrome in a patient after mitral valve replacement [4].

Diagnostic criteria for Takotsubo syndrome, viz. (a) new electrocardiographic abnormalities; either ST elevations or T wave inversion, (b) absence of obstructive coronary artery disease, and (c) transient akinesia or dyskinesia of the left ventricle, etc. have been described [5].

Despite the characteristic, near pathognomonic pattern of LV wall motion abnormalities and the typical course of the syndrome, the clinician needs to differentiate it from three potential scenarios:

i. Suboptimal myocardial protection which may lead to potentially fully recoverable myocardial microcirculatory disturbance; highly likely in the presence of predisposing factors (LV hypertrophy or coronary artery disease) and abnormal LV function after weaning off CPB.

ii. Impairment of LV function with LV sphericalization due to loss of the mitral annuloventricular continuity, described in the past after conventional MVR with excision of both leaflets and papillary muscles. Such impairment may occur transiently but has been much more frequently described as a cause for permanent postoperative LV dysfunction. The posterior subvalvular apparatus was preserved in our patient. One may wonder whether at least some of the cases of post-surgical transient LV sphericalization described in the past were, in fact, cases of the Takatsubo-syndrome not yet known at that time. Intriguingly, some of the cases of post-MVR transient LV sphericalization described in the past, had occurred in postmenopausal women, who seem to be more susceptible to this syndrome.

iii. Tachycardiomyopathy, another cause of transient LV dysfunction, can occur in patients with atrial fibrillation with a fast ventricular response over a prolonged period of time.

We therefore believe that the awareness of Takatsubo syndrome after MVR with/without annulo-ventricular continuity is relevant in individual patients as it may mimic similar LV ballooning.

References

1. Athanasiou T, Chow A, Rao C, Aziz O, Siannis F, Ali A, Ara Darzi A, Wells F. Preservation of the mitral valve apparatus: evidence synthesis and critical reappraisal of surgical techniques. Eur J Cardiothorac Surg 2008;33:391-401.[Abstract/Free Full Text]
2. Satoh H, Tateishi H, Uchida T. Takotsubo-type cardiomyopathy due to multivessel spasm. In: Kodama K, Haze K, Hon M, editors. Clinical aspects of myocardial injury: from ischemia to heart failure [in Japanese]. Tokyo: Kagakuyouronsya Co.; 1990. pp. 56-64.
3. Dote K, Sato H, Tateishi H, Uchida T, Ishihara M. Myocardial stunning due to simultaneous multivessel spasm; review of fives cases [in Japanese]. J Cardiol 1991;21:203-214.[Medline]
4. Kogan A, Ghosh P, Schwammenthal E, Raanani E. Takotsubo syndrome after cardiac surgery. Ann Thorac Surg 2008;85:1439-1441.[Abstract/Free Full Text]
5. Bybee KA, Kara T, Prasad A, Lerman A, Barsness GW, Wright RS, Rihal CS. 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]

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				C. Rao and T. Athanasiou Reply to ghosh et Al. Eur. J. Cardiothorac. Surg., August 1, 2008; 34(2): 467 - 467. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Probal K. Ghosh Alexander Kogan Ehud Raanani Permission Requests Citing Articles Citing Articles via HighWire Google Scholar Articles by Ghosh, P. K. Articles by Raanani, E. PubMed Articles by Ghosh, P. K. Articles by Raanani, E. Related Collections Cardiac - other Valve disease