A rare ventriculography: midventricular Takotsubo syndrome

A 65-year-old woman was transferred to our Cardiology Department due to a syncope in the sitting position, without prodromes and with mandibular trauma, after a 30-minute walk. Apart from dyslipidemia, she had no other cardiovascular risk factors, being physically active. She was under emotional stress due to her father's recent death. Physical examination was unremarkable except for a small bruise on the jaw. First electrocardiogram showed sinus tachycardia, 120/min, 1 mm ST-elevation in aVL and a less than 1 mm ST-depression in the inferior leads. Troponin T was elevated (maximum value of 519 pg/ml; reference value of <14 pg/ml). Transthoracic echocardiogram showed a mild depression on the left ventricular (LV) systolic function (LV ejection fraction of 45%) with severe hypokinesia of all midventricular segments. Coronariography revealed no significant coronary lesions and ventriculography unveiled an akinesia of all LV median segments, with preserved contractility of basal and apical segments (Fig.), compatible with the diagnosis of the midventricular variant of Takotsubo Syndrome (TTS). She initiated medical therapy and had no complications during hospitalization. She was discharged medicated with bisoprolol 2.5 mg, ramipril 2.5 mg and atorvastatin 40 mg.

The patient had a clinical picture suggestive of the midventricular variant of TTS, probably precipitated by emotional stress related to the death of a close family member. TTS is characterized by an acute and transient ventricular dysfunction in the absence of obstructive coronary artery disease. It is frequently precipitated by significant emotional stress or serious physical illness, and usually presents with circumferential wall motion abnormalities, irrespective of the epicardial vascular territory distribution. Although the apical form is the most common in TTS, midventricular, basal (reverse), focal, biventricular and isolated right ventricle variants have also been described.^, Although TTS is a reversible condition, several complications can occur during the acute phase, such as acute heart failure, ventricular arrhythmias and cardiogenic shock. Treatment is supportive, usually consisting in beta-blockers (especially in the presence of LV outflow tract obstruction) and renin-angiotensin system inhibitors, while catecholamines should be avoided considering the pathophysiology of this syndrome. Antiplatelet treatment and statins are appropriate in the presence of atherosclerosis. Ventricular function recovers completely in 3 to 6 months, and the recurrence rate is relatively low, but not negligible. Clinicians should be aware of less common variants of this syndrome, due to the therapeutic and prognostic implications in making the correct diagnosis.

None.

The authors would like to thank Dr. Hugo Vinhas for the support during the coronary angiogram and ventriculography, and also Dr. Dina Bento and Dr. Jorge Mimoso for the experience insight and for the review of the manuscript.