A 34-year-old woman was referred to the emergency department for right lower quadrant abdominal pain. She had no cardiovascular risk factors or medical history, except for four previous general anaesthesias for minor surgery, with no complications. She did not complain of chest pain and troponin concentration was not elevated. Neutrophils were elevated on blood count (11,000/mL) and C-reactive protein concentration was normal. Abdominal CT showed a moderately hypertrophied appendix (10-mm diameter) with small adjacent peritoneal effusion consistent with appendicitis. Exploratory laparoscopy was then decided upon. Ten minutes after induction of anaesthesia (using sufentanil, propofol and cisatracurium), she developed circulatory inefficiency secondary to ventricular fibrillation. Successful defibrillation was obtained after two external electric shocks. Surgery was delayed. Transthoracic echocardiography revealed a global hypokinesia of the left ventricle with significant impairment of LV ejection fraction (35%). The electrocardiogram recorded at rest after resuscitation was strictly normal. The next day, prospectively triggered cardiac CT (GE Discovery 750HD, GE HealthCare, Waukesha, WI, USA) was performed (dose-length product, 76 Gy.cm; ≈1.5 mSv), which eliminated coronary artery disease or anomalous origin of coronary arteries. To limit artefacts in this tachycardic patient (heart rate, 85 beats per minute) with a contraindication to beta-blocker therapy, we centred the prospective acquisition window on the end-systole (phase 40%). Multiplanar reconstructions showed hypokinesia of the midventricular part of the left ventricle, contrasting with the normal thickening of the basal and apical sectors ( Fig. 1A–C ). Midventricular Takotsubo cardiomyopathy was therefore considered and cardiac MRI was performed the day after. Cardiac MRI (Siemens Symphony TIM, 1.5T, Erlangen, Germany) confirmed the circumferential midventricular akinesia with normal thickening of basal and apical segments ( Fig. 1D : end-diastole; E : end-systole; Appendix A: Videos 1 and 2 ) and no LGE ( F ). Follow-up MRI at 1 month showed complete recovery of global and regional LV function ( G : end-diastole; H : end-systole; Appendix A: Videos 3 and 4 ) and absence of LGE ( I ), thus confirming the diagnosis of acute reversible midventricular Takotsubo cardiomyopathy associated with ventricular fibrillation and general anaesthesia.
