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case_images: Electrocardiographic dynamic changes. Progressive development of electrocardiographic alterations typical of takotsubo syndrome, including ST-segment elevation, QTc prolongation, and T-wave inversion.
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case_images: Electrocardiographic showed normal sinus rhythm with Q waves in lead III and biphasic T waves in lead III and aVF leads (Figure 1A), whereas echocardiography revealed a 65% left ventricular ejection fraction (LVEF; Supplementary material online, Videos S1 and S2). Once there, he started complaining of worsening chest pain, and a 12-lead ECG showed ST-segment elevation in V1-V3, suggesting LAD territory ischaemia (Figure 1B). ECG showed sinus rhythm, persistent ST-segment elevation in the precordial leads, and new-onset QT interval prolongation (500 ms; Figure 1C). Echocardiography revealed akinesia involving all LV apical segments (see Supplementary material online, Video S10), and, within a few minutes, also all mid-segments, accompanied by hyperkinesia of the basal segments and severely impaired global LV systolic function (LVEF 35%), leading to the suspicion of TTS (see Supplementary material online, Video S11).
case_images: Coronary angiography. Coronary angiography views of the left coronary artery (A, B) and right coronary artery before (C) and after (D) the first percutaneous coronary angioplasty.
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case_images: Coronary angiography showed patency of previous stents and non-significant atherosclerosis in the left anterior descending (LAD) artery (Figure 2A and B; Supplementary material online, Videos S3 and S4). Conversely, the RCA had a significant stenosis at the ostium and a subocclusive in-stent restenosis in the mid-segment (Figure 2C; Supplementary material online, Video S5), which were challenging to treat due to heavy calcifications and vessel tortuosity. After successfully placing three drug-eluting stents in the RCA (Figure 2D; Supplementary material online, Video S6), the patient was transferred to the intensive care unit (ICU) for observation.
case_images: Coronary angiography. Coronary angiography views of the right coronary artery before (A) and after (B) the second percutaneous coronary angioplasty.
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case_images: Given the evolving clinical scenario, a second coronary angiogram was performed, which demonstrated patency of all stents, but identified subocclusion of the RCA postero-lateral branch (Figure 3A; Supplementary material online, Video S8), which was addressed with successful balloon angioplasty (Figure 3B; Supplementary material online, Video S9), with complete relief of chest pain.
case_images: Cardiac biomarkers levels. Dynamic changes in high-sensitivity troponin T and N-terminal pro-B-type natriuretic peptide levels during hospitalization. Cardiac biomarkers levels from a previous blood sample performed before hospitalization are also reported.
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case_images: T peaked at 906 ng/L (normal range <14 ng/L) after 5 days (Figure 4). The patient was prescribed dual antiplatelet therapy (aspirin and ticagrelor), atorvastatin/ezetimibe 10/10 mg combination, as well as guideline-directed anti-remodelling medications: metoprolol 50 mg b.i.d, sacubitril/valsartan 24/26 mg b.i.d., eplerenone 50 mg, and empagliflozin 10 mg.
case_images: Cardiac magnetic resonance T2-weighted short-tau inversion recovery sequences (short-axis views; A) show diffuse transmural oedema (arrows) involving the apical and mid-segments of the septum, anterior, and inferior walls, as well as subendocardial oedema of the basal infero-lateral wall. T1-weighted gradient echo-inversion recovery sequences (short-axis views; B) show late gadolinium enhancement (arrows) limited to the basal infero-lateral wall.
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case_images: Cardiac magnetic resonance (CMR) imaging performed three days after the cardiac arrest confirmed the diagnosis of TTS, while demonstrating a partial improvement in LV systolic dysfunction (LVEF 45%) and, notably, diffuse myocardial oedema without evidence of delayed enhancement in the LAD territory (Figure 5; Supplementary material online, Video S12).