Transient apical ballooning in hypertrophic obstructive cardiomyopathy.

A 79-year-old white woman with known hypertrophic obstructive cardiomyopathy (HOCM) presented with sudden-onset chest pain and no identifiable stressor. Examination suggested a new apical 3/6 systolic murmur and pulmonary edema. A 12-lead electrocardiogram showed anterolateral wall ischemia. The patient’s peak troponin T level was 2.5 ng/mL. Echocardiography revealed a basal hypertrophied septum (Fig. 1) with a resting left ventricular (LV) outflow gradient of approximately 20 mmHg, severe mitral valve regurgitation, and apical akinesis. No obstruction of the coronary arteries was seen on arteriography. Simultaneous LV and aortic pressure tracing showed dynamic LV outflow tract (LVOT) obstruction as evidenced by the Brockenbrough-Braunwald-Morrow sign (Fig. 2). Severe mitral regurgitation, anteroapical ballooning, and basal hyperkinesis with a low LV ejection fraction (LVEF, 0.25) were noted on ventriculography (Fig. 3). The patient was stabilized with oxygen, diuretics, and β-blockers, and she was discharged from the hospital on the 4th day. At her 2-month follow-up visit, the apical ballooning had completely resolved (LVEF, 0.65), and the dynamic LVOT obstruction was relatively less severe.