Pathophysiology of the Syndrome: Biventricular Takotsubo Cardiomyopathy: Case Report and General Discussion

In recent years, our understanding of the physiologic mechanisms of transient takotsubo cardiomyopathy has improved because of the growing use of emergent heart catheterization in patients who present with severe ischemic syndromes. However, even this procedure has revealed only that, in most patients with takotsubo syndrome, the sudden onset of ventricular dysfunction is not due to fixed coronary artery occlusions. We present a case of transient takotsubo cardiomyopathy with an exceptional feature—uneven impairment of both right and left ventricular function, or biventricular takotsubo—and we discuss a novel, comprehensive theory that we have devised to explain the pathophysiology of this syndrome''s many manifestations.Key words: Acetylcholine/diagnostic use, angina pectoris, variant, coronary endothelial dysfunction, coronary vasospasm/physiopathology, takotsubo cardiomyopathy/classification/diagnosis/physiopathology, ventricular dysfunction, left/etiology/diagnosis, ventricular dysfunction, right/etiology/diagnosisOnly during the last 2 decades have Japanese authors^1,2 specifically categorized transient takotsubo cardiomyopathy (TTC) as an entity in itself. Before that time, TTC was often called “acute myocardial infarction with normal coronary arteries.”³ Its prevalence is probably as low today as in the remote past. However, acute coronary artery syndromes are now studied aggressively with emergent heart catheterization, which documents better than any previous means the transience of the myopathy and the presence of apparently normal coronary arteries. These circumstances have stimulated the quest to generate a pathophysiologic concept broad enough to encompass the full clinical spectrum of TCC.Apical ballooning (resulting in a systolic takotsubo or “octopus trap”) is the most frequent and emblematic feature of TTC. The use of this term has successfully promoted awareness of the disease in the cardiology community at large, but it has also impeded clinicians'' understanding of the breadth of this entity''s clinical manifestations. Our persistently inadequate knowledge of the nature and spectrum of TTC seems to warrant an update on the subject.Here, we present a case of right ventricular (in union with left ventricular) TTC. In addition, we discuss a pathophysiologic theory that our group has recently proposed, which might explain the newly discovered and broad spectrum of TTC clinical manifestations.