Atypical form of Tako-Tsubo cardiomyopathy.

A 22-year-old male smoker with no other cardiovascular risk factors presented within the first hours after a successful appendicectomy with severe acute chest pain accompanied by nausea. An ECG showed ST-segment elevation in leads I, VL, V2V4 and concurrent ST-depression in leads II, III, VF (Fig. 1). He was immediately transferred to the CCU where chest pain was relieved after nitrate therapy. Laboratory results found CK peak of 230 U/L and positive Troponine T (peak: 1.14 ug/L). A coronary angiogram was performed a few hours later, showing normal coronary arteries. Left ventricular angiogram showed akynesia of the middle segments of the inferior and anterior walls with preserved apical motion. A CMR study was performed within 24 hours, confirming circumferential akinesia of the middle segments of the left ventricle in the cine sequences (Fig. 2A), resulting in moderate global left ventricular systolic dysfunction (ejection fraction: 42%). Late gadolinium images did not show enhancement (Fig. 2B), ruling out the presence of myocardial infarction as well as myocarditis. A transaxial T2weighted sequence did not show abnormal regional increase of the myocardial signal intensity (Fig. 3). The patient remained asymptomatic and was discharged at day 5 with a normal ECG (Fig. 4). A second CMR study was performed 2 weeks after the acute episode showing a complete normalization of regional contractility and normal left ventricular ejection fraction (65%) (Fig. 5). Atypical forms of Tako-Tsubo cardiomyopathy have been recently described (1–4). In our case, as in all these reports, clinical data suggestive of Tako-Tsubo syndrome were present in patients in whom transient left ventricular ballooning was not localized at the apical ventricular portion, as classically described in this entity. The case we describe, however, is the first one reported, among atypical forms, studied with late gadolin-