We read with interest Silvestre et al.'s letter to the editors. The authors pointed out that early-onset heart failure (≥30 days) and late-onset heart failure (>30 days) may have different etiologies. They based this idea on their observation of 2 cases of stress-related cardiomyopathy in patients after liver transplantation (LT).[1] They also alluded to cirrhotic cardiomyopathy as a possible etiology of these differences.

Echocardiography is an imaging modality that can be used to characterize stress-related cardiomyopathy.[2] It is unlikely that this could have been missed by the reading cardiologists. In order to rigorously document the etiology of heart failure, we frequently reviewed echocardiography reports even 4 to 6 weeks after LT. However, we failed to recognize stress-related cardiomyopathy in these reports. It is possible that we might have missed a diagnosis of stress-related cardiomyopathy because the majority of such patients (>95%) are known to improve after 4 to 6 weeks.[2, 3] One could argue that this is a rare diagnosis, as mentioned by Silvestre et al. in their letter, and so a generalization regarding the etiology of heart failure in LT patients cannot be made on the basis of these case reports.

One of the major aims of our study was to enunciate the risk factors for heart failure in LT patients. Many of these factors are shared by cirrhotic cardiomyopathy. We agree with Silvestre et al. that cirrhotic cardiomyopathy might have played a role in these early heart failure episodes, but we intended to include them because our observations had suggested that the risk factors for cirrhotic cardiomyopathy and late-onset heart failure were similar. Moreover, we did not find coronary artery disease or elevated blood pressure to be a significant risk factor for heart failure in this population.[4]

Seventeen cases developed heart failure within the first 30 days, and 9 cases (>50%) suffered from perioperative myocardial infarction. Only 12 of these 17 cases developed systolic heart failure, and they eventually included all 9 cases with perioperative myocardial infarction. Our study was underpowered to evaluate and draw conclusions about predictors of heart failure on the basis of 5 individuals. Larger multicenter studies may help to explain the differences in the risk factors for early-onset and late-onset heart failure.

  • Waqas Qureshi, M.D.

  • Chetan Mittal, M.D.

  • Fatima Khalid, M.D.

  • Section of Cardiovascular Medicine

  • Department of Internal Medicine

  • Wake Forest University School of Medicine

  • Winston Salem, NC 27157


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  • 1
    Tachotti Pires LJ, Cardoso Curiati MN, Vissoci Reiche F, Silvestre OM, Mangini S, Carballo Afonso R, et al. Stress-induced cardiomyopathy (takotsubo cardiomyopathy) after liver transplantation—report of two cases. Transplant Proc 2012;44:24972500.
  • 2
    Pilgrim TM, Wyss TR. Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome: a systematic review. Int J Cardiol 2008;124:283292.
  • 3
    Leurent G, Larralde A, Boulmier D, Fougerou C, Langella B, Ollivier R, et al. Cardiac MRI studies of transient left ventricular apical ballooning syndrome (takotsubo cardiomyopathy): a systematic review. Int J Cardiol 2009;135:146149.
  • 4
    Qureshi W, Mittal C, Ahmad U, Alirhayim Z, Hassan S, Qureshi S, Khalid F. Clinical predictors of post-liver transplant new-onset heart failure. Liver Transpl 2013;19:701710.