To the Editor:

I appreciated the article by Roy and colleagues1  in the Texas Heart Institute Journal. To the authors' knowledge, theirs were the first reported cases in which apical-variant hypertrophic cardiomyopathy was masked by apical ballooning from stress-induced cardiomyopathy. The authors added information about 5 reported cases of patients with hypertrophic cardiomyopathy (HCM) who had experienced an episode of takotsubo cardiomyopathy, all of whom had the obstructive HCM “with asymmetric septal hypertrophy, not apical-variant HCM.” What was actually observed is a recently detected phenomenon of apparent left ventricular (LV) apical hypertrophy,2,3  which occasionally is seen in the subacute and chronic phase of convalescence from takotsubo cardiomyopathy. It is caused by transient myocardial edema.4  Kato and colleagues3  observed apical hypertrophy of the LV at approximately 3 weeks after onset, when the wall motion had improved; the ventricular wall gradually became thinner, and the transient apical hypertrophy was attributed to hypertrophic signaling in the myocardium, which was stimulated by catecholamines.3  Myocardial edema with a hypertrophic LV apex has been reproducibly detected on cardiac magnetic resonance images4  and echocardiograms. Whether the LV hypertrophy1  represents apical HCM or takotsubo-induced myocardial edema can be resolved by observing subsequent electrocardiograms of these patients for chronically persisting giant negative T waves5  and R waves6  in the mid-precordial leads, and by comparing old and follow-up echocardiograms.

References

References
1.
Roy
RR
,
Hakim
FA
,
Hurst
RT
,
Simper
D
,
Appleton
CP.
Two cases of apical ballooning syndrome masking apical hypertrophic cardiomyopathy
.
Tex Heart Inst J
2014
;
41
(
2
):
179
83
.
2.
Madias
JE.
Two cases of reversible left ventricular hypertrophy during recovery from takotsubo cardiomyopathy: hypertrophy or myocardial edema after an attack of takotsubo syndrome?
Echocardiography
2013
;
30
(
8
):
989
.
3.
Kato
T
,
Ban
Y
,
Kuruma
S
,
Ishida
S
,
Doi
C
,
Iura
T
,
et al
.
Two cases of reversible left ventricular hypertrophy during recovery from takotsubo cardiomyopathy
.
Echocardiography
2013
;
30
(
4
):
E92
4
.
4.
Perazzolo Marra
M
,
Zorzi
A
,
Corbetti
F
,
De Lazzari
M
,
Migliore
F
,
Tona
F
,
et al
.
Apicobasal gradient of left ventricular myocardial edema underlies transient T-wave inversion and QT interval prolongation (Wellens' ECG pattern) in takotsubo cardiomyopathy
.
Heart Rhythm
2013
;
10
(
1
):
70
7
.
5.
Yamaguchi
H
,
Ishimura
T
,
Nishiyama
S
,
Nagasaki
F
,
Nakanishi
S
,
Takatsu
F
,
et al
.
Hypertrophic nonobstructive cardiomyopathy with giant negative T waves (apical hypertrophy): ventriculographic and echocardiographic features in 30 patients
.
Am J Cardiol
1979
;
44
(
3
):
401
12
.
6.
Madias
JE.
Electrocardiogram in apical hypertrophic cardiomyopathy with a speculation as to the mechanism of its features
.
Neth Heart J
2013
;
21
(
6
):
268
71
.

Author notes

Letters to the Editor should be no longer than 2 double-spaced typewritten pages and should generally contain no more than 6 references. They should be signed, with the expectation that the letters will be published if appropriate. The right to edit all correspondence in accordance with Journal style is reserved by the editors.