Tako-tsubo cardiomyopathy, acute coronary syndrome, or both?

Stefano Svab, Elena Pasotti, Tiziano Moccetti, and Giovanni B. Pedrazzini*

Cardiocentro Ticino, Lugano, Switzerland

* Corresponding author. Tel: +41 918053178, Fax: +41 918053173, Email: [email protected]

A 76-year-old Caucasian woman known for hypertension and former cigarette smoking was admitted for acute dyspnoea and chest pain with 12-lead ECG highly evocative for sub-acute anterior myocardial infarction (Panel A). Based on the urgent coronary angiogram showing a complex left anterior descending (LAD) artery proximal bifurcation lesion (Medina 1/1/1) with preserved peripheral flow (Panels B and C) and only a slight increase in troponin I (maximal value 5.5 μg/L, normal value <0.9 μg/L), the decision was taken to submit the patient to accelerated surgical revascularization. Unexpectedly, both the ventriculogram (Panel D) and the initial transthoracic echocardiography (Panel E) showed a severe antero-apico-basal akinesia, whereby surgical intervention was postponed. Based on the complete normalization of the LV function 1 week after the acute event (Panel F), we hypothesized an apical ballooning syndrome in a patient with concomitant severe LAD lesion most probably corresponding to an acute coronary syndrome. In the current literature it is still a matter of debate whether both pathologies might coexist simultaneously. This case strongly supports the hypothesis of a possible cohabitation.

Panel A. ECG at admission, showing ST elevation in anterior leads. Panels B and C. LAO cranial and RAO cranial angiographic views, respectively, showing a complex LAD proximal bifurcation lesion with preserved flow (Supplementary material online, Video S2 and S3). Panel D. Ventriculogram showing severe antero-apico-basal akinesia (Supplementary material online, Video S1). Panel E. Transthoracic echocardiogram at admission confirming severe antero-apico-basal akinesia (Supplementary material online, Video S4). Panel F. Transthoracic echocardiogram performed 1 week later, showing a normalization of LV function (Supplementary material online, Video S5). LM, left main artery; LAD, left anterior descending artery; DB, diagonal branch; RCX, circumflex artery.

Supplementary material is available at European Heart Journal online.