Endomyocardial biopsy should be considered to rule out myocarditis in patients presenting with LV apical ballooning syndrome, as myocarditis can mimic Takotsubo cardiomyopathy.
Apical ballooning may represent immune-mediated myocarditis; this case leaves open whether biopsy is warranted in suspected Takotsubo.
Endomyocardial biopsy (EMB), the diagnostic gold standard for myocarditis, has not been systematically performed in the reported case series of Takotsubo cardiomyopathy, although proposed Mayo Criteria specify exclusion of myocarditis. Moreover, there is no specific recommendation for infarct-like acute myocarditis in the recently published guidelines on the role of EMB. Here we present a thoroughly documented case fulfilling both the proposed Mayo criteria for Takotsubo cardiomyopathy and the World Health Organization criteria for active, virus-negative, immune-mediated myocarditis. Since myocarditis can mimic acute myocardial infarction with normal coronary arteries, EMB should be performed to rule out myocarditis in patients presenting with LV apical ballooning syndrome (or Takotsubo cardiomyopathy).
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Caforio et al. (2009) studied this question.