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A 56-year-old woman presented with cognitive impairment, confusion and slowed speech, muscle cramps and peripheral paraesthesia preceded by vomiting. Blood tests revealed severe hypokalaemia, hyponatremia, hypomagnesemia and hypocalcaemia. Following a diagnosis of Takotsubo cardiomyopathy based on ultrasonography, the patient was treated with electrolyte supplementation and recovered within 48h. When heart failure is suspected, electrolyte abnormalities should be carefully ruled out as they can affect cardiac function. LEARNING POINTS• The association between electrolyte abnormalities and Takotsubo cardiomyopathy has still not been well established in the literature.• Hypomagnesemia and hypocalcaemia can contribute to cardiac akinesia and so should be ruled out in heart failure.• Correction of hypomagnesemia and hypocalcaemia is an important and an under-estimated part of the optimal treatment of cardiac failure. KEYWORDSTakotsubo cardiomyopathy, hypomagnesemia, hypocalcaemia, heart failure CASE DESCRIPTION A 56-year-old woman was admitted to the emergency department because of cognitive impairment, confusion and slowed speech, muscle cramps and peripheral paraesthesia lasting a few days. The patient's family reported very poor food intake in preceding months, and some episodes of vomiting after eating during the previous few days. The patient's medical history was negative for both somatic and psychiatric disorders. The only medication she was taking was a PPI. She had been smoking cigarettes since adolescence (40 pack-years). Blood tests revealed severe hypokalaemia (1.7 mmol/l), hyponatremia (120 mmol/l), hypomagnesemia (0.35 mmol/l) and hypocalcaemia (ionized calcium 0.80 mmol/l), so the patient was admitted to the intensive care department for electrolyte supplementation. Complete neurological recovery was achieved in 48 h after partial correction of electrolyte anomalies. During the following days, we treated progressive cardiac failure with non-invasive ventilation and the administration of diuretics.

Although the benefits of using the left internal mammary artery to bypass the left anterior descending artery (LAD) have been extensively ascertained, freedom from major cardiovascular events and survival after coronary artery bypass grafting (CABG) also correlate with the completeness of revascularisation. Hence, careful selection of the second-best graft conduit is crucial for CABG success. The more widespread use of saphenous vein grafts contrasts with the well-known long-term efficacy of multiple arterial grafting, which struggles to emerge as the procedure of choice due to concerns over increased technical difficulties and higher risk of postoperative complications. Conduit choice is at the discretion of the operator instead of being discussed by the heart team, where cardiologists are not usually engaged in such decisions due to a hypothetical lack of technical knowledge. Furthermore, according to the ESC/EACTS guidelines, traditional CABG remains the gold standard for multi-vessel coronary artery disease with complex LAD stenosis, but hybrid procedures using percutaneous coronary intervention for non-LAD targets could combine the best of two worlds. With the aim of raising the cardiologist’s awareness of the surgical treatment options, we provide a comprehensive overview of the anatomical, functional and clinical aspects guiding the decision-making process in CABG strategy.