Letters to the Editor

Comment on Takotsubo Syndrome in a Patient Following a Heller Esophageal Myotomy and Its Plausible Triggers

To the Editor:

The article by Ural et al,¹ published in the spring 2015 issue of the Journal, about the 59-year-old man who suffered an episode of Takotsubo syndrome (TTS) in the immediate postoperative period after an uneventful laparoscopic esophageal Heller myotomy with Dor fundoplication is of interest particularly regarding its plausible trigger(s). A normal electrocardiogram (ECG) does not exclude TTS, but the authors do not refer to any subsequent ECGs after the initial postoperative ECG and do not address whether such tracings revealed any changes, particularly T-wave inversions or QT_c interval prolongation.² Also, transient low QRS voltage has been recently reported in association with TTS,³ and it would be helpful to evaluate whether this patient showed such changes. The authors remark that their “patient's 30-pound weight loss and progressive fatigue may have been the precipitating events leading to his acute myocardial stunning,”¹ but anesthesia, all the drugs administered (including the small amount of epinephrine), a variety of operative and nonoperarive procedures, and postoperative complications have been triggers for the emergence of TTS.⁴ Finally, the specific myocardial topography (particularly apical or midventricular) should not be the prerequisite for the diagnosis of TTS, but any myocardial wall contraction abnormalities or global hypokinesis can occasionally be the imaging phenotypes of TTS.