Could Deliberate Temporal-Distancing of Mitral Clip Deployment and Proactive Vasodilation Have Averted Takotsubo Syndrome?

Raone et al¹ recently reported on an 81-year-old man who, immediately after undergoing an elective mitral valve (MV) transcatheter edge-to-edge repair (M-TEER) for severe primary mitral regurgitation, developed “a striking global reduction in left ventricular performance,” which the authors attributed initially to an afterload mismatch (AM) and managed with a vasodilator, with their patient subsequently, after transfer to the intensive care unit, being diagnosed with Takotsubo syndrome (TTS). The pathophysiology of TTS remains elusive²; some investigators have theorized that some form of “segmental AM” may be operating as the pathophysiologic mechanism of TTS with an acute rise of segmental afterload due to the resultant regional hypocontractility of the apical/midventricular myocardium and hypercontractility of the heart's base, induced by the autonomic sympathetic nervous system surge and/or rise in blood-borne catecholamines.3, 4, 5 I do not share the opinion of Raone et al that their patient had TTS rather than AM, and I believe that their patient had both; indeed, I think that their patient had initially an AM, engendered by the M-TEER, which acted as the trigger for the emergence of TTS. This is not an uncommon scenario of a medical/surgical condition resulting in TTS (eg, an acute myocardial infarction causing TTS). It is conceivable that the AM and consequently TTS would not have materialized had this patient had the deployment of the second MV clip with some time delay after the first one, thus imposing the expected AM gradually. Along the same proactive vein, simultaneous initiation of a vasodilator with the implementation of M-TEER might be considered. Of course, these 2 proposed recommendations need to be incorporated in the M-TEER protocol, and evaluated prospectively.