Objective
Takotsubo cardiomyopathy (TCM) is characterized by transient hypokinesis of the left ventricular apex, and is associated with emotional and physical stress. Wall motion abnormality is typically seen in left ventricular (LV) apex, however atypical localizations can be seen. Here, we present a case of TCM with mid-ventricular wall balooning.
Methods
A 52-year-old woman presented with chest pain and syncope, following emotional stress due to death of her husband. On ECG, the rhythm was sinusal. There were slight ST segment elevation in leads V1-V3 and T wave inversion in leads V1-V3, aVL. Prominent U waves and sinusal bradycardia were also present. At admission, CK-MB was 27 U/L, total CK: 312 U/L, troponin I: 0.47 ng/ml (N: 0-0.15). She had smoking and early menapause as coronary risk factors. Blood biochemistry was unremarkable except mild hypokalemia. Haemogram was normal.
Results
The following day, coronary angiography and left ventriculography were performed with the diagnosis of acute coronary syndrome. There were fibrofatty atherosclerotic plaques in all three epicardial coronary arteries. Left ventriculography revealed mid-anterolateral ballooning with sparing of the apex and other left ventricular segments (Figure 1). Transthoracic echocardiography demonstrated mid-anterolateral wall dyskinesis with a global ejection fraction of 55%. During follow-up troponin I levels were 0.44 ng/ml and 0.08 ng/ml, respectively. The patient was discharged with optimal medical therapy. At one month control, echocardiography returned to normal with no wall motion abnormality. The ECG was also normal with mild sinusal bradycardia. Our diagnosis was an atypical variant of TCM with midventricular involvement.
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