Takotsubo or not Takotsubo Syndrome: A Case Report

Background: Takostubo cardiomyopathy is defined by the presence of transient wall motion abnormalities, most of the time in the form of an apical ballooning and without coronary occlusion. Causes remain unclear. Psychological or physical stress could cause this pathology related to catecholamine cardiotoxicity. The distinction between Takotsubo cardiomyopathy and myocardial infarction is not always easy to make. This particular clinical case is a good illustration of that situation.

Case Presentation: A 76-year-old woman presented to the emergency department with chest pain. The initial electrocardiogram was consistent with ST-Segment Elevation Myocardial Infarction (STEMI). The coronary angiography showed healthy coronary arteries, and the ventriculography reveals apical dyskinesia. After the procedure, the patient was hemodynamically stable. However, two hours later, she presented with hypotension, and a transthoracic echocardiogram revealed cardiac tamponade. Surgical drainage was urgently performed and showed a small apical perforation. The perforation was repaired, and she finally recovered. An MRI was performed twenty-two days later and showed a non-dilated left ventricle with preserved overall function, apical akinesia as well as evidence of an apical post-infraction status consisting of subendocardium to apical transmural scarring.

Conclusion: The initial presentation was consistent with Takotsubo cardiomyopathy considering electrocardiogram modification, healthy coronary arteries, and apical dyskinesia. The patient did not have a clear trigger, but she was known for anxiety. The findings with MRI were consistent with myocardial infarction. However, the surgical intervention could have changed the appearance of the MRI making a definitive diagnosis difficult.