"Nipple" and "hawk's beak" appearances on contrast left ventricular angiography in Takotsubo syndrome: what's in a sign?

Appearances at left ventricular (LV) contrast angiography of patients presenting with Takotsubo syndrome (TTS) vary depending on the cardiac region that is impacted by the affliction. Desmet et al. recently reported [1] on their series of 119 patients with TTS, who had LV contrast angiography at cardiac catheterization, 92 of whom had the apical variety of TTS, characterized by systolic ballooning of the LV apex with preservation of LV basal contractility; out of these 92 patients, 28 (30.4%) had a “very small zone with preserved contractility in the most apical portion of the LV”, for which the authors coined the term “apical nipple sign”, which by contrast was not present in any of 405 patients “who had been treated for anterior ST-elevation myocardial infarction (STEMI) by emergency percutaneous intervention on the left anterior descending artery”. Thus the “apical nipple sign” may aid in the differential diagnosis of apical TTS from anterior STEMI. Roncalli et al. [2] recently reported the case of a 76-year-old womanwith the midventricular variant of TTS, characterized by LV midventricular systolic ballooning with preservation of LV apical contractility, which gave the appearance of a “hawk's beak” to the LV apex, prompting the authors to proposing the “hawk's beak” as an angiographic diagnostic sigh of the midventricular variant of TTS. Since TTS is characterized by a large variation in LV wall motion abnormalities (LVWMAs) of individual afflicted patients, more such signs are expected to be observed at contrast LV angiography. In addition there have been descriptions of patents with TTS with repeat presentations featuring different patterns of LVWMAs, or involvement of LV and/or right ventricle, during the same, or temporally different, admissions for TTS [3–14]. Furthermore territorial “migration” of LVWMAs has been noted in some patients in serial imaging studies, with akinesis involving different LV regions and recovery of previously involved regions [15]. The remarks by Desmet et al. [1] about their patients with LV apical TTS with the “apical nipple sign” as clinical TTS phenotypes representing presentation of “a very extensive form of the mid-ventricular variant of apical TTS, just nearly missing evolvement to truly complete apical akinesis”, or that the “apical nipple sign” may represent the “earliest stage of mechanical recovery of a true apical ballooning” are relevant of a need for serial heart imaging for patients admitted with suspected, or subsequent proven, TTS. Certainly such repeated imaging cannot be implemented with contrast LV angiography, or computed axial tomography angiography, or magnetic resonance angiography, but with echocardiography. The later modality, which may be argued that may lack sensitivity for such a role, particularly in interrogation of LV apex, should be vigorously evaluated in its classic application, and the currently enhanced format of two-dimensional speckle tracking [16]. The hypotheses of Desmet et al. about the mechanism of the “apical nipple sign” being due to very extensive form of the mid-ventricular variant of apical TTS [1] and Roncalli et al. about the “hawk's beak” as a sign of a midventricular variant of TTS [2], notwithstanding these 2 LV contrast angiographic appearances, may not be substantially different phenotypes of TTS. We should all be on the look-out for more LV and right ventricular angiographic “signs”, and naturally for more names, as more cases of TTS are being detected.