case_images: PMC11157011_01
case_images: Twelve-lead ECG at hospital admission in the first episode (A) and recurrence of Takotsubo syndrome (B).
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case_images: F1
case_images: T-waves in the infero-lateral leads (Figure 1A). The coronary angiography documented tortuous epicardial coronary arteries, free from significant lesions, with diffuse slow flow (Figures 2A,B). Since the ECG showed slight QRS widening, left anterior hemiblock, and ST-segment elevation in the lateral leads (Figure 1B), the patient underwent an immediate invasive angiography, which excluded again the presence of coronary artery stenosis and showed the apical ballooning pattern of the left ventricle, as in the previous episode (Figures 2E-H).
case_images: Coronary angiography and left ventriculography imaging performed in 2021 (A-D) and 2023 (E-H). Red dotted lines underline the apical akinesia during left ventricular systole.
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case_images: F2
case_images: T-waves in the infero-lateral leads (Figure 1A). The coronary angiography documented tortuous epicardial coronary arteries, free from significant lesions, with diffuse slow flow (Figures 2A,B). Hyperkinesia of the basal segments, akinesia of the middle and apical segments, and ejection fraction (EF) of 35% were seen at left ventriculography (Figures 2C,D). Since the ECG showed slight QRS widening, left anterior hemiblock, and ST-segment elevation in the lateral leads (Figure 1B), the patient underwent an immediate invasive angiography, which excluded again the presence of coronary artery stenosis and showed the apical ballooning pattern of the left ventricle, as in the previous episode (Figures 2E-H).
case_images: Cardiac magnetic resonance imaging performed in March 2021 (A-E), September 2021 (F-J), and March 2023 (K-O). Red dotted lines underline the apical akinesia during left ventricular systole.
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case_images: PMC11157011_01_fcvm-11-1418316-g003.jpg
case_images: F3
case_images: On day 5, a cardiac magnetic resonance (CMR) confirmed the diagnosis (Figures 3A-E) showing in addition the presence of a small intraventricular thrombotic formation (15 x 8 mm) for which oral anticoagulant therapy was given. The clinical course was uncomplicated and, 6 months after the event, a planned CMR found complete functional recovery of the left ventricle, oedema reduction, disappearance of the intraventricular thrombus, subendocardial late gadolinium-enhancement (LGE) at the basal inferolateral wall level (Figures 3F-J) as a result of remote necrosis. TTS relapse, the patient performed a third CMR. The imaging pattern was similar to that observed 2 years before: extended akinesia at the level of the middle and apical segments, which appeared diffusely oedematous in the STIR sequences; stable subendocardial LGE with ischemic pattern at the basal infero-lateral wall (Figures 3K-O).