No abstract

Takotsubo syndrome (TTS) has been reported in various clinical conditions. Coronary artery fistula (CAF) is diagnosed in 0.2- 0.4% of patients undergoing coronary angiography. Pathologic communication between coronary artery (e.g., left anterior de¬scending coronary artery – LAD) and cardiac chambers (e.g., left ventricle – LV) is cameral type of CAF which particularly predis¬pose to myocardial ischemia due to a steal syndrome. Eight cases of coexistent TTS and CAF have been reported so far; in 6 of them LAD cameral fistulas drained LV, in 2 others communications between coronary arteries and pulmonary artery were found. The authors describe a case of a 75-year-old female, admitted due to chest pain and dyspnea. Her clinical picture with ST-segment elevation in ECG, moderately increased troponin I and apical ballooning in echocardiography, was more typical for TTS than for myocardial infarction; besides that, color doppler imaging was suggestive of multiple CAF to LV. Coronary angiography showed communication between all (normal) coronary arteries and LV. Throughout the conservative therapy, first, an improve¬ment and then normalization of LV function were observed after 2 and 6 days, respectively. Chest x-ray and computed tomogra¬phy revealed mediastinal tumor (eventually diagnosed as lung cancer). Cardiac magnetic resonance performed after one month did not show late gadolinium enhancement. During the course of 24 months follow-up, she was taking bisoprolol and ramipril and her cardiologic state remained stable, even during chemotherapy and radiotherapy. The authors collected the clinical data of all 9 cases with concomitant TTS and CAF. Specific TTS triggering factors/predisposing conditions were present in all patients, which has indicated that coexistence of TTS and CAF is rather coincidental.

Mechanical heart compression, including that from mediastinal tumor, may cause Brugada-like ECG pattern. Such ECG pattern might also be observed in intracardiac tumor obstructing the right ventricular out"ow tract (RVOT). Eight cases with Brugada-like ECG and tumors involving RVOT have been described so far; 4 growing in the mediastinum (with one example of in"ammatory mass), 3 with intracardiac location, and 1 being an organized pericardial hematoma. The authors present other 3 cases of intracardiac metastatic tumors in RVOT and Brugada-like ECG pattern with coved ST-segment elevation in the right precordial leads. All patients had negative history of cardiovascular disease or familiar malignant arrhythmia occurrence. ECG were done routinely; none of the patients had chest pain or an increased level of cardiac troponins. In all patients, neoplastic disease was at advanced stage. A 76-year-old male, had a history of four neoplasms: bladder cancer was being treated with chemotherapy, while prostate, tongue, and lung cancers had been resected years ago and no signs of local relapse were found. A 78-year-old female, was diagnosed with colon cancer 1 month after an episode of venous thromboembolism. Six months after the resection of cancer, second focus of adenocarcinoma was found in the rectum. Third patient, a 65-year-old-male had undergone nephrectomy for renal cancer a year before cardiac metastasis diagnosis.