Apical ballooning "tako-tsubo" syndrome associated with transient left ventricular outflow tract obstruction.

A 72-year-old female without prior cardiovascular history presented with intermittent crushing chest pain associated with diaphoresis and weakness for 2 days prior to admission. An electrocardiogram (EKG) revealed ST segment elevation across the anterior precordial leads (Fig. 1). On initial examination, the patient was hypotensive (88/40 mmHg) and tachycardic (110 bpm) with a grade III/VI harsh systolic murmur along the left sternal border. An initial troponin level of 0.36 ng/dL (reference range of 0.0–0.1 ng/dL) was noted. Transthoracic echocardiography (TTE) revealed a dilated and akinetic left ventricular (LV) apex. Compensatory hyperkinesis of basal LV segments with associated systolic anterior motion (SAM) of the mitral valve was noted (Fig. 2 and Video Clip). A dynamic LV outflow tract (LVOT) gradient by continuous wave Doppler (CW) was 90 mmHg. The patient was taken emergently to the cardiac catheterization laboratory where coronary arteriography revealed minimal luminal irregularities. Left ventriculography was not performed. Based on TTE findings along with the absence of significant epicardial coronary disease, a diagnosis of apical ballooning “takotsubo” syndrome (ABS) was made. The patient was treated with fluids and beta blockers; and within 24 hours the murmur re-