Post-mortem Takotsubo cardiomyopathy diagnosis: the challenge is open!
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LETTER TO THE EDITOR
Post-mortem Takotsubo cardiomyopathy diagnosis: the challenge is open! Francesca Indorato1
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Giovanni Bartoloni1
Accepted: 22 February 2016 Ó Springer Science+Business Media New York 2016
In 2015 we reported a fatal case of a previously healthy 70-year-old woman who suffered an out-of-hospital cardiac arrest and cardiac rupture during emotional distress, due to Takotsubo cardiomyopathy (TCM) [1]. We appreciated the interesting Letter to the Editor by Angelini [2], who has long been involved in research aimed at elucidating the cause and pathophysiology of this entity [3]. As he stated, whenever a patient dies within 24 h after the onset of TCM-like symptoms, it is important to study the case in detail. Leading from the points highlighted in his letter, we would like to comment further on these topics. The diagnostic criteria for TCM consist of a large spectrum of findings (e.g., echocardiographic evidences; scintigraphic images; coronary angiogram; cardiac magnetic resonance), obviously not detectable in the histopathological post-mortem changes for several reasons: 1.
2.
The gross transverse section of cardiac apex, as showed in Fig. 3 of our manuscript [1], may be misleading for the correct evaluation of the whole parietal wall thickness. Unfortunately, the slice was unavoidably selected because it showed the maximal extension of hemorrhagic penetrating lesion. Moreover, we postulate that the transient apical ballooning disappears because the intracavitary pressure decreases soon after death. Immunohistochemical demonstration of acetylcholine complex has never been demonstrated in the post-
& Francesca Indorato [email protected] 1
Department ‘‘G.F. Ingrassia’’, Section of Legal Medicine, University of Catania, Via S. Sofia, 87 – Edificio C, 95123 Catania, Italy
3.
4.
mortem endothelium. Therefore, acetylcholine testing of endothelial dysfunction may be a further finding and a good research start-point. The pathophysiology of TCM complicated by cardiac rupture (myocardial contractile abnormalities in close territories leading to the myocardial tear) may differ from non-complicated TCM ones. Moreover, in literature other reported cases showed values of blood pressure and pulse (blood pressure of 124/67 mmHg and heart rate of 76 b.p.m. [4]) similar to our case (blood pressure of 122/70 mmHg and heart rate of 95 b.p.m.). The histologic findings of eosinophilic infiltration, spotty coagulation necrosis, and spotty fibrosis suggest that the pathologic changes were subacute and chronic, in fact TCM has been included among cardiomyopathies recently classified which are, by definition, chronic illnesses [5].
We thank Prof. Angelini and agree with him on the fact that a definitive means of diagnosing TCM at autopsy is needed. The proposal of a set of histopathological criteria for post-mortem diagnosis of TCM will be the subject of a subsequent manuscript.
References 1. Indorato F, Akashi YJ, Rossitto C, Raffino C, Bartoloni G. Takotsubo cardiomyopathy associated with rupture of the
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