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Letters to the Editor
“Nipple” and “hawk's beak” appearances on contrast left ventricular angiography in Takotsubo syndrome: What's in a sign? John E. Madias ⁎ Icahn School of Medicine at Mount Sinai, New York, NY, United States Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States
a r t i c l e
i n f o
Article history: Received 27 February 2014 Accepted 9 March 2014 Available online 16 March 2014 Keywords: Takotsubo syndrome Wall motion abnormalities Left ventricular contrast angiography Takotsubo variants
To the Editor: Appearances at left ventricular (LV) contrast angiography of patients presenting with Takotsubo syndrome (TTS) vary depending on the cardiac region that is impacted by the affliction. Desmet et al. recently reported [1] on their series of 119 patients with TTS, who had LV contrast angiography at cardiac catheterization, 92 of whom had the apical variety of TTS, characterized by systolic ballooning of the LV apex with preservation of LV basal contractility; out of these 92 patients, 28 (30.4%) had a “very small zone with preserved contractility in the most apical portion of the LV”, for which the authors coined the term “apical nipple sign”, which by contrast was not present in any of 405 patients “who had been treated for anterior ST-elevation myocardial infarction (STEMI) by emergency percutaneous intervention on the left anterior descending artery”. Thus the “apical nipple sign” may aid in the differential diagnosis of apical TTS from anterior STEMI. Roncalli et al. [2] recently reported the case of a 76-year-old woman with the midventricular variant of TTS, characterized by LV midventricular systolic ballooning with preservation of LV apical contractility, which gave the appearance of a “hawk's beak” to the LV apex, prompting the authors to proposing the “hawk's beak” as an angiographic diagnostic sigh of the midventricular variant of TTS. Since TTS is characterized by a large variation in LV wall motion abnormalities (LVWMAs) of individual afflicted patients, more such signs are expected to be observed at contrast LV angiography. In addition there have been descriptions of patents with TTS with repeat presentations featuring different patterns of LVWMAs, or involvement of LV and/or right ventricle, during the same, or temporally different, admissions for TTS [3–14]. Furthermore territorial “migration” of LVWMAs has been noted in some patients in serial imaging studies, with akinesis involving different LV regions and recovery of previously involved regions [15]. The remarks by Desmet et al. [1] about their patients with LV apical TTS with the “apical nipple sign” as clinical TTS phenotypes representing presentation of “a very extensive form of the mid-ventricular variant of apical TTS, just nearly missing evolvement ⁎ Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, United States. Tel.: + 1 718 334 5005; fax: +1 718 334 5990. E-mail address: [email protected]. 0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2014.03.053
to truly complete apical akinesis”, or that the “apical nipple sign” may represent the “earliest stage of mechanical recovery of a true apical ballooning” are relevant of a need for serial heart imaging for patients admitted with suspected, or subsequent proven, TTS. Certainly such repeated imaging cannot be implemented with contrast LV angiography, or computed axial tomography angiography, or magnetic resonance angiography, but with echocardiography. The later modality, which may be argued that may lack sensitivity for such a role, particularly in interrogation of LV apex, should be vigorously evaluated in its classic application, and the currently enhanced format of two-dimensional speckle tracking [16]. The hypotheses of Desmet et al. about the mechanism of the “apical nipple sign” being due to very extensive form of the mid-ventricular variant of apical TTS [1] and Roncalli et al. about the “hawk's beak” as a sign of a midventricular variant of TTS [2], notwithstanding these 2 LV contrast angiographic appearances, may not be substantially different phenotypes of TTS. We should all be on the look-out for more LV and right ventricular angiographic “signs”, and naturally for more names, as more cases of TTS are being detected. References [1] Desmet W, Bennett J, Ferdinande B, et al. The apical nipple sign: a useful tool for discriminating between anterior infarction and transient left ventricular ballooning syndrome. Eur Heart J Acute Cardiovasc Care Dec 17 2013 [Epub ahead of print]. [2] Roncalli J, Carrie D, Fauvel JM, Losordo DW. A “hawk's beak” to identify the new transient midventricular Tako-Tsubo syndrome. Int J Cardiol 2008;127:e179–80. [3] Joe BH, Hwang HJ, Park CB, et al. Takotsubo cardiomyopathy recurrence with left ventricular apical ballooning following isolated right ventricular involvement: a case report. Exp Ther Med 2013;6:260–2. [4] Angelini P, Monge J, Simpson L. Biventricular takotsubo cardiomyopathy: case report and general discussion. Tex Heart Inst J 2013;40:312–5. [5] Behnes M, Baumann S, Borggrefe M, Haghi D. Biventricular takotsubo cardiomyopathy in a heart transplant recipient. Circulation 2013;128:e62–3. [6] Kano S, Munakata R, Inami T, Takano M, Seino Y, Shimizu W. Recurrent Takotsubo cardiomyopathy with variable left ventricular obstruction and morphologies. J Am Coll Cardiol 2014;63:e3. [7] Tran K, Milne N, Duhig E, Altman M. Inverted Takotsubo cardiomyopathy— clinicopathologic correlation. Am J Forensic Med Pathol 2013;34:217–21. [8] Singh K, Parsaik A, Singh B. Recurrent takotsubo cardiomyopathy: variable pattern of ventricular involvement. Herz Jul 25 2013 [Epub ahead of print]. [9] Ratanapo S, Srivali N, Cheungpasitporn W, Suksaranjit P, Chongnarungsin D, Bischof EF. Reported cases of recurrent takotsubo cardiomyopathy with variant forms of left ventricular dysfunction. Am J Med 2013;126:e27. [10] Elikowski W, Małek M, Łanocha M, et al. Reversible dilated cardiomyopathy as an atypical form of takotsubo cardiomyopathy. Pol Merkur Lekarski 2013;34:219–23. [11] Waller CJ, Vandenberg B, Hasan D, Kumar AB. Stress cardiomyopathy with an “inverse” takotsubo pattern in a patient with acute aneurysmal subarachnoid hemorrhage. Echocardiography 2013;30:E224–6. [12] Alhaj E, Ahmad US, Niazi OT, et al. Atypical stress-induced cardiomyopathy: a case series. Acta Cardiol 2013;68:222–5. [13] Fernandes A, Trigo J, Mota P, Leitão-Marques A. Atypical Takotsubo syndrome. BMJ Case Rep 2013;22:2013. [14] Liu K, Carhart R. “Reverse McConnell's sign?”: a unique right ventricular feature of Takotsubo cardiomyopathy. Am J Cardiol 2013;111:1232–5. [15] Jouhra F, Dworakowski R, MacCarthy P. Atypical form of Takotsubo cardiomyopathy. BMJ Case Rep Feb 18 2013, http://dx.doi.org/10.1136/bcr-2012-008376. [16] David-Cojocariu A, de Hemptinne Q, Vandenbossche JL, Unger P. Assessment of variant forms of Takotsubo cardiomyopathy by two-dimensional speckle tracking echocardiography. Eur Heart J Cardiovasc Imaging Dec 29 2013 [Epub ahead of print].
Letters to the Editor
“Nipple” and “hawk's beak” appearances on contrast left ventricular angiography in Takotsubo syndrome: What's in a sign? John E. Madias ⁎ Icahn School of Medicine at Mount Sinai, New York, NY, United States Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United States
a r t i c l e
i n f o
Article history: Received 27 February 2014 Accepted 9 March 2014 Available online 16 March 2014 Keywords: Takotsubo syndrome Wall motion abnormalities Left ventricular contrast angiography Takotsubo variants
To the Editor: Appearances at left ventricular (LV) contrast angiography of patients presenting with Takotsubo syndrome (TTS) vary depending on the cardiac region that is impacted by the affliction. Desmet et al. recently reported [1] on their series of 119 patients with TTS, who had LV contrast angiography at cardiac catheterization, 92 of whom had the apical variety of TTS, characterized by systolic ballooning of the LV apex with preservation of LV basal contractility; out of these 92 patients, 28 (30.4%) had a “very small zone with preserved contractility in the most apical portion of the LV”, for which the authors coined the term “apical nipple sign”, which by contrast was not present in any of 405 patients “who had been treated for anterior ST-elevation myocardial infarction (STEMI) by emergency percutaneous intervention on the left anterior descending artery”. Thus the “apical nipple sign” may aid in the differential diagnosis of apical TTS from anterior STEMI. Roncalli et al. [2] recently reported the case of a 76-year-old woman with the midventricular variant of TTS, characterized by LV midventricular systolic ballooning with preservation of LV apical contractility, which gave the appearance of a “hawk's beak” to the LV apex, prompting the authors to proposing the “hawk's beak” as an angiographic diagnostic sigh of the midventricular variant of TTS. Since TTS is characterized by a large variation in LV wall motion abnormalities (LVWMAs) of individual afflicted patients, more such signs are expected to be observed at contrast LV angiography. In addition there have been descriptions of patents with TTS with repeat presentations featuring different patterns of LVWMAs, or involvement of LV and/or right ventricle, during the same, or temporally different, admissions for TTS [3–14]. Furthermore territorial “migration” of LVWMAs has been noted in some patients in serial imaging studies, with akinesis involving different LV regions and recovery of previously involved regions [15]. The remarks by Desmet et al. [1] about their patients with LV apical TTS with the “apical nipple sign” as clinical TTS phenotypes representing presentation of “a very extensive form of the mid-ventricular variant of apical TTS, just nearly missing evolvement ⁎ Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, United States. Tel.: + 1 718 334 5005; fax: +1 718 334 5990. E-mail address: [email protected]. 0167-5273/$ – see front matter © 2014 Elsevier Ireland Ltd. All rights reserved. http://dx.doi.org/10.1016/j.ijcard.2014.03.053
to truly complete apical akinesis”, or that the “apical nipple sign” may represent the “earliest stage of mechanical recovery of a true apical ballooning” are relevant of a need for serial heart imaging for patients admitted with suspected, or subsequent proven, TTS. Certainly such repeated imaging cannot be implemented with contrast LV angiography, or computed axial tomography angiography, or magnetic resonance angiography, but with echocardiography. The later modality, which may be argued that may lack sensitivity for such a role, particularly in interrogation of LV apex, should be vigorously evaluated in its classic application, and the currently enhanced format of two-dimensional speckle tracking [16]. The hypotheses of Desmet et al. about the mechanism of the “apical nipple sign” being due to very extensive form of the mid-ventricular variant of apical TTS [1] and Roncalli et al. about the “hawk's beak” as a sign of a midventricular variant of TTS [2], notwithstanding these 2 LV contrast angiographic appearances, may not be substantially different phenotypes of TTS. We should all be on the look-out for more LV and right ventricular angiographic “signs”, and naturally for more names, as more cases of TTS are being detected. References [1] Desmet W, Bennett J, Ferdinande B, et al. The apical nipple sign: a useful tool for discriminating between anterior infarction and transient left ventricular ballooning syndrome. Eur Heart J Acute Cardiovasc Care Dec 17 2013 [Epub ahead of print]. [2] Roncalli J, Carrie D, Fauvel JM, Losordo DW. A “hawk's beak” to identify the new transient midventricular Tako-Tsubo syndrome. Int J Cardiol 2008;127:e179–80. [3] Joe BH, Hwang HJ, Park CB, et al. Takotsubo cardiomyopathy recurrence with left ventricular apical ballooning following isolated right ventricular involvement: a case report. Exp Ther Med 2013;6:260–2. [4] Angelini P, Monge J, Simpson L. Biventricular takotsubo cardiomyopathy: case report and general discussion. Tex Heart Inst J 2013;40:312–5. [5] Behnes M, Baumann S, Borggrefe M, Haghi D. Biventricular takotsubo cardiomyopathy in a heart transplant recipient. Circulation 2013;128:e62–3. [6] Kano S, Munakata R, Inami T, Takano M, Seino Y, Shimizu W. Recurrent Takotsubo cardiomyopathy with variable left ventricular obstruction and morphologies. J Am Coll Cardiol 2014;63:e3. [7] Tran K, Milne N, Duhig E, Altman M. Inverted Takotsubo cardiomyopathy— clinicopathologic correlation. Am J Forensic Med Pathol 2013;34:217–21. [8] Singh K, Parsaik A, Singh B. Recurrent takotsubo cardiomyopathy: variable pattern of ventricular involvement. Herz Jul 25 2013 [Epub ahead of print]. [9] Ratanapo S, Srivali N, Cheungpasitporn W, Suksaranjit P, Chongnarungsin D, Bischof EF. Reported cases of recurrent takotsubo cardiomyopathy with variant forms of left ventricular dysfunction. Am J Med 2013;126:e27. [10] Elikowski W, Małek M, Łanocha M, et al. Reversible dilated cardiomyopathy as an atypical form of takotsubo cardiomyopathy. Pol Merkur Lekarski 2013;34:219–23. [11] Waller CJ, Vandenberg B, Hasan D, Kumar AB. Stress cardiomyopathy with an “inverse” takotsubo pattern in a patient with acute aneurysmal subarachnoid hemorrhage. Echocardiography 2013;30:E224–6. [12] Alhaj E, Ahmad US, Niazi OT, et al. Atypical stress-induced cardiomyopathy: a case series. Acta Cardiol 2013;68:222–5. [13] Fernandes A, Trigo J, Mota P, Leitão-Marques A. Atypical Takotsubo syndrome. BMJ Case Rep 2013;22:2013. [14] Liu K, Carhart R. “Reverse McConnell's sign?”: a unique right ventricular feature of Takotsubo cardiomyopathy. Am J Cardiol 2013;111:1232–5. [15] Jouhra F, Dworakowski R, MacCarthy P. Atypical form of Takotsubo cardiomyopathy. BMJ Case Rep Feb 18 2013, http://dx.doi.org/10.1136/bcr-2012-008376. [16] David-Cojocariu A, de Hemptinne Q, Vandenbossche JL, Unger P. Assessment of variant forms of Takotsubo cardiomyopathy by two-dimensional speckle tracking echocardiography. Eur Heart J Cardiovasc Imaging Dec 29 2013 [Epub ahead of print].
