Letter to the Editor
Basal takotsubo syndrome: A multifaceted entity with potential implications
Miocardiopatia de Takotsubo basal: uma entidade multifacetada com implicações potenciais
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ANT: anterior wall; ANT_SEPT: anteroseptal wall; BP: blood pressure; GLS: global longitudinal strain; INF: inferior wall; LAT: lateral wall; POST: posterior wall; SEPT: septal wall.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "Nikolaos Miaris, Nearchos Kasinos, Maria Karakosta, Sarantos Linardakis, Dimitra Maritsa, Nikolaos Patsourakos, Evangelos Pisimisis" "autores" => array:7 [ 0 => array:2 [ "nombre" => "Nikolaos" "apellidos" => "Miaris" ] 1 => array:2 [ "nombre" => "Nearchos" "apellidos" => "Kasinos" ] 2 => array:2 [ "nombre" => "Maria" "apellidos" => "Karakosta" ] 3 => array:2 [ "nombre" => "Sarantos" "apellidos" => "Linardakis" ] 4 => array:2 [ "nombre" => "Dimitra" "apellidos" => "Maritsa" ] 5 => array:2 [ "nombre" => "Nikolaos" "apellidos" => "Patsourakos" ] 6 => array:2 [ "nombre" => "Evangelos" "apellidos" => "Pisimisis" ] ] ] ] ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255121003188?idApp=UINPBA00004E" "url" => "/08702551/0000004000000008/v1_202108010531/S0870255121003188/v1_202108010531/en/main.assets" ] ] "en" => array:12 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Letter to the Editor</span>" "titulo" => "Basal takotsubo syndrome: A multifaceted entity with potential implications" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "625" "paginaFinal" => "626" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "Kenan Yalta, Cihan Ozturk, Tulin Yalta, Ertan Yetkin" "autores" => array:4 [ 0 => array:4 [ "nombre" => "Kenan" "apellidos" => "Yalta" "email" => array:2 [ 0 => "kyalta@gmail.com" 1 => "akenanyalta@trakya.edu.tr" ] "referencia" => array:4 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] 3 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "Cihan" "apellidos" => "Ozturk" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "Tulin" "apellidos" => "Yalta" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "Ertan" "apellidos" => "Yetkin" "referencia" => array:3 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 2 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Trakya University, Cardiology Department, Edirne, Turkey" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Trakya University, Pathology Department, Edirne, Turkey" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Derindere Hospital, Cardiology Department, Istanbul, Turkey" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Miocardiopatia de Takotsubo basal: uma entidade multifacetada com implicações potenciais" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">In clinical practice, takotsubo syndrome (TTS) occasionally manifests as atypical variants potentially affecting myocardial segments other than the left ventricular (LV) apex, including basal, midventricular, or other segments.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,2</span></a> In their article recently published in the <span class="elsevierStyleItalic">Journal</span>, Miaris et al. reported an interesting case of basal TTS in a young woman following cesarean delivery.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Accordingly, we would like to make a few comments on this case and outline some further implications of basal TTS in this clinical setting.</p><p id="par0010" class="elsevierStylePara elsevierViewall">First, diagnosis of atypical TTS variants is a significant challenge, largely due to the non-specific changes on the electrocardiogram (ECG) along with the absence of the typical apical ballooning pattern on imaging modalities.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Consistent with this, the patient was reported to be in normal sinus rhythm. However, we wonder about the authors’ explanation regarding the potential mechanisms of documented relative bradycardia (50 bpm on the ECG), which seems quite unusual in such a TTS case under extreme stress. Accordingly, is it a drug-induced effect or a phenomenon associated with basal TTS? We hold the opinion that certain factors including the Bezold-Jarish reflex (potentially arising due to a sudden increase in circumferential wall stress of the LV base in association with dilatation and severe dysfunction of this segment) and episodes of sinus node ischemia – potentially associated with intermittent compression of coronary arteries including the circumflex artery (traveling along the left atrioventricular groove) by the dilated LV basal segments – might have served as the mechanisms of relative sinus bradycardia in this patient.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Second, atypical TTS variants (compared to the classical pattern) mostly arise as a consequence of more severe adrenergic discharge, which is potentially associated with serious clinical scenarios (neurological conditions, attempted suicide, etc.).<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">2</span></a> Therefore, it seems quite likely that the patient suffered extreme stress. On the other hand, severe adrenergic discharge in the setting of TTS was previously suggested to be associated with acute coronary microvascular dysfunction (presenting with coronary slow flow [CSF] in the major coronary arteries) and consequent adverse events including acute heart failure and arrhythmogenesis.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">3</span></a> Accordingly, did the patient have a CSF pattern on invasive coronary angiography or cardiac arrhythmias during her hospital stay?</p><p id="par0020" class="elsevierStylePara elsevierViewall">Third, basal TTS may also have important hemodynamic implications due to emerging acute mitral regurgitation (MR).<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Characteristically, acute MR in patients with basal TTS may be considered a functional and reversible entity.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Recently, another case of basal TTS presenting with transient severe MR was also reported in a young woman following attempted suicide by drug overdose.<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">4</span></a> It thus seems likely that basal TTS has a particular predilection for young females under extreme stress.<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">1,4</span></a> Mechanistically, acute MR seems to arise in a subgroup of basal TTS patients presenting with excessive dilatation of the LV base and consequent mitral annular dilatation (as may have occurred in the present case<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a>). However, dysfunction in the basal portions of the papillary muscles may also contribute to emerging acute MR in these patients. Nevertheless, the presence of a central jet on the echocardiogram suggests annular dilatation as the dominant mechanism of MR in the patient reported by Miaris et al.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> Accordingly, we wonder about the mitral annulus diameter of the patient during her TTS episode. Importantly, the severity of MR should be thoroughly investigated in patients with basal TTS, particularly in those with mild LV systolic dysfunction, but with severe hemodynamic compromise. In this context, temporary LV unloading strategies such as intra-aortic balloon pumping could yield a significant therapeutic benefit in the acute setting.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Finally, the authors used global longitudinal strain (GLS) as an adjunctive diagnostic parameter in their patient.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">1</span></a> However, we hold the opinion that assessment of GLS generally adds little to the conventional echocardiogram in diagnosing TTS. On the other hand, persistently abnormal GLS values following complete recovery from TTS could help identify cases with subclinical myocardial dysfunction in the long term, who usually present with symptoms such as exercise intolerance.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> Moreover, survivors of atypical TTS variants may be more likely to suffer subclinical myocardial dysfunction, possibly due to the residual cardiomyotoxic effects of extreme adrenergic discharge on myocardial energetics and contractile reserve.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">5,6</span></a> Accordingly, we wonder about the GLS values of the patient beyond one month (if any).</p><p id="par0030" class="elsevierStylePara elsevierViewall">In conclusion, basal TTS could have important clinical implications in both the short and long term, mostly attributable to its specific cardiac location and associated factors (including extreme adrenergic discharge). However, further aspects of this phenomenon still need to be investigated.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Financial disclosure</span><p id="par0035" class="elsevierStylePara elsevierViewall">None.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Financial disclosure" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflicts of interest" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:6 [ 0 => array:3 [ "identificador" => "bib0035" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Basal type ‘broken heart’ in a postpartum woman: Utility of speckle tracking echocardiography" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "N. 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Taylan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.11909/j.issn.1671-5411.2020.07.010" "Revista" => array:6 [ "tituloSerie" => "J Geriatr Cardiol" "fecha" => "2020" "volumen" => "17" "paginaInicial" => "447" "paginaFinal" => "448" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32863828" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0045" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The assessment of coronary microvascular dysfunction: An integral part of risk-stratification in Takotsubo cardiomyopathy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Yalta" 1 => "M. Gurdogan" 2 => "G. Taylan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.repc.2020.02.008" "Revista" => array:6 [ "tituloSerie" => "Rev Port Cardiol" "fecha" => "2020" "volumen" => "39" "paginaInicial" => "357" "paginaFinal" => "358" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32540215" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0050" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Basal Takotsubo syndrome with transient severe mitral regurgitation caused by drug use: a case report" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "G. Albenque" 1 => "Y. Bohbot" 2 => "Q. Delpierre" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Eur Heart J Case Rep" "fecha" => "2020" "volumen" => "4" "paginaInicial" => "1" "paginaFinal" => "6" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0055" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Systemic inflammation in patients with Takotsubo syndrome: a review of mechanistic and clinical implications" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Yalta" 1 => "E. Yetkin" 2 => "T. 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Zorkun" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.15420/cfr.2018:24:2" "Revista" => array:6 [ "tituloSerie" => "Card Fail Rev" "fecha" => "2018" "volumen" => "4" "paginaInicial" => "14" "paginaFinal" => "20" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/29892470" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/08702551/0000004000000008/v1_202108010531/S0870255121002560/v1_202108010531/en/main.assets" "Apartado" => array:4 [ "identificador" => "55963" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Carta ao Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/08702551/0000004000000008/v1_202108010531/S0870255121002560/v1_202108010531/en/main.pdf?idApp=UINPBA00004E&text.app=https://revportcardiol.org/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0870255121002560?idApp=UINPBA00004E" ]
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| 2023 Setembro | 30 | 20 | 50 |
| 2023 Agosto | 26 | 16 | 42 |
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| 2021 Dezembro | 22 | 31 | 53 |
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