Occurrence of late gadolinium enhancement in ventricular ballooning or Tako-Tsubo syndrome: increased wall stress should not be overlooked

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Abstract
With great interest, we read the article by Rolf et al.1 The histological basis of late gadolinium enhancement (LGE) in magnetic resonance imaging (MRI) was examined in 15 patients with transient ventricular ballooning or the so-called Tako-Tsubo syndrome. While all patients exhibited increased collagen-1 in endomyocardial biopsies, it was higher in five patients who showed LGE. After 14 days, LGE and collagen-1 normalized. Since focal LGE pattern did not match the areas of increased collagen that were diffusely spread over the left ventricle, collagen-1 alone cannot explain the occurrence of LGE.