Madias, John E.

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Address for correspondence: John E. Madias, MD, FACC, FAHA Division of Cardiology, Elmhurst Hospital Center, 79-01 Broadway, Elmhurst, NY 11373, USA, tel: (718) 334-5005, fax: (718) 334-5990, e-mail: madiasj@nychhc.orgReceived: 13.05.2022 Accepted: 31.08.2022This article is available in open access under Creative Common Attribution-Non-Commercial-No Derivatives 4.0 International (CC BY-NC-ND 4.0) license, allowing to download articles and share them with others as long as they credit the authors and the publisher, but without permission to change them in any way or use them commercially.Cardiology Journal2022, Vol. 29, No. 6, 897–898DOI: 10.5603/CJ.2022.0109Copyright © 2022 Via MedicaISSN 1897–5593eISSN 1898–018XEDITORIAL COMMENTCLINICAL CARDIOLOGYInquiries about a patient with a “snail-like” takotsubo syndrome variant  John E. Madias1, 21Icahn School of Medicine at Mount Sinai, New York, NY, United States2Division of Cardiology, Elmhurst Hospital Center, Elmhurst, NY, United StatesThis editorial  accompanies the  article on page 1051A fascinating case report by Genc et al. [1], accompanied by a very impres-sive video of a patient with a “snail-like” focal takotsubo syndrome (TTS) variant underscores the contribution of videos in the appreciation of regional myocardial contraction abnormalities (RMCAs) in patients with TTS, and particularly in patients with “focal” abnormalities where such RMCAs are expected to be limited in extent. In addition, an inherent differential diagnosic prob-lem (not encountered in the present case) is that “focal” TTS often needs to be differentiated from RMCAs related to an acute coronary syndrome, conventionally associated with a single culprit coronary artery occlusion or atherosclerotic plaque destabilization, while RMCAs in patients with non-focal TTS are more extensive occupying myocardial regions subtended by more than one coronary ar-tery (e.g., apical, midventricular, and reverse TTS variants) comprise component RMCAs involving septal, anterior, inferior, and lateral myocardial territories, which would not be expected to be associated with a blood flow-limited occlusion or critical stenosis of a single coronary artery. I understand that the format of the paper present-ing this case report was such that did not permit the authors [1] to include more details regarding this 70-year- -old woman with TTS; however due tothe rarity of the “focal” TTS variant,a few details provided by the authors,may be of value to the readers and in-vestigators alike. This belief promptsme to request the authors’ kind re-sponse on the following commentsand inquiries: 1) The patient’s lack ofsymptoms fits with the low troponin Iand B-type natriuretic peptide, particularly the latter, value levels; 2) Was there a repeat echocar-diogram done during hospitalization, and what were the findings?; 3) Was there a regional longitudinal strain (Bull’s Eye Plot) carried out in the follow-up echocardiogram(s)?; 4) Was the patient on any drug therapy prior to her presentation, including hormones like estrogens or progestins [2]?; 5) Did the QTc shorten in subsequent electrocardiograms, and when, in the follow-up course?; 6) The elec-trocardiogram changes of ST-segment elevation in leads II, III, and aVF are incongruent with the topography of the left ventricular “focal” RMCAs (e.g., one would have expected such RMCAs to be associated with some changes in the precordial elec-trocardiogram leads and/or leads I and aVL [3, 4]; 7) What was the electrocardiogram evolution during hospitalization?; 8) Did the patient develop invertedT-waves, and in what electrocardiogram leads?Conflict of interest: None declared897www.cardiologyjournal.orgReferences1. Genc A, Sobolewski J, Bachorski W, et al. The focal takotsubo syndrome presenting with the snail-like left ventricle. Cardiol J. 2021; 28(4): 636–637, doi:  10.5603/CJ.2021.0068, indexed in Pubmed: 34240396.2. Ioannou A. Takotsubo cardiomyopathy associated with dydroges-terone use. BMJ Case Rep. 2021; 14(11): e246553, doi: 10.1136/bcr-2021-246553, indexed in Pubmed: 34844971.3. Madias JE. Electrocardiogram lead-specific QRS attenuation in an atypical midventricular case of Takotsubo syndrome. J Electrocardiol. 2013; 46(6): 728–729, doi:  10.1016/j.jelectro-card.2013.08.008, indexed in Pubmed: 24028997.4. Madias JE. A patient with midventricular takotsubo: any attenuation in the amplitude of the QRS complexes in subse- quent electrocardiograms? Am J Emerg Med. 2018; 36(7): 1303–1304, doi: 10.1016/j.ajem.2017.11.004, indexed in Pubmed: 29117901.898 www.cardiologyjournal.orgCardiology Journal 2022, Vol. 29, No. 6

Inquiries about a patient with a “snail-like” takotsubo syndrome variant

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Inquiries about a patient with a “snail-like” takotsubo syndrome variant

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