case_images: PMC5122644_01
case_images: (A) Electrocardiography shows prominent ST-segment elevation in precordial leads. (B) Bedside echocardiography shows left ventricular apical ballooning with ventricular septal defect resulting from apical septal rupture (arrow) with a left-to-right shunt. (C) Coronary angiography shows no significant stenosis. LA, left atirum; LV, left ventricle; RV, right ventricle.
case_images: ymj-58-248-g001.jpg
case_images: PMC5122644_01_ymj-58-248-g001.jpg
case_images: F1
case_images: An electrocardiography showed prominent ST-segment elevation in leads V2-5 (Fig. 1A). Bedside echocardiography showed an akinesis from the mid to apical left ventricle, but preserved systolic function within the basal segment (Fig. 1B). In addition, a ventricular septal defect resulting from apical septal rupture with a left-to-right shunt was noted (Fig. 1B). Angiography demonstrated no significant stenosis of the epicardial coronary arteries (Fig. 1C), suggesting the diagnosis of ventricular septal rupture complicated by takotsubo cardiomyopathy with right ventricular involvement.
case_images: (A and B) An anterolateral (black triangle) and inferior (gray triangle) wall of the LV have necrotic changes with hemorrhage. (C) The RV (white triangle) also has necrotic changes with hemorrhage. Free wall rupture (black arrow) is noted. (D) Ventricular septal wall rupture (white arrow) is observed. (E) The injured myocytes are disrupted in multiple levels (arrows) and interposed by histiocytes and lymphocytes. Groups of myocytes (squares) have increased eosinophilic staining with loss of central nuclei (hematoxylin-eosin, x200). The infiltrating lymphocytes are CD3/CD4 positive helper T cells (CD3, x400) (inlet). (F) Intact myocytes with myofibrils are red; injured myocytes are contrasted in blue (Masson Trichrome, x200). LV, left ventricle; RV, right ventricle.
case_images: ymj-58-248-g002.jpg
case_images: PMC5122644_01_ymj-58-248-g002.jpg
case_images: F2
case_images: Ventricular septal wall rupture was confirmed (Fig. 2D). Also, another rupture within the right ventricular free wall measuring 20x18 mm was noted (Fig. 2C), which had led to the cardiac tamponade that presented in the operating room. Pathological examination of the ruptured ventricular septum revealed disrupted myocytic integrity in multiple foci with lymphohistiocytic infiltrate and myocytic necrosis (Fig. 2E and F).