heart syndrome with acute onset and characterized by chest symptoms, elevated ST segment on electrocardiogram (ECG), transient balloon-like asynergy in the apical regions and hyperkinesis in the basal regions on left ventriculography, minimal myocardial enzymatic release, and no significant luminal narrowing of the coronary artery, was originally named by Sato et al as 'Takotsubo' cardiomyopathy 1 after its distinctive appearance on left ventriculography of this syndrome. In Japan, the takotsubo, which is a unique fishing pot ('tsubo') with a round bottom and narrow neck, is used for trapping octopus ('tako'). Since then, many reports of the disease have been published, but the details of its mechanism are still unclear. We describe a rare case of ampulla cardiomyopathy of both ventricles, in which the microcirculation disturbance was evaluated using 99m Tc-tetrofosmin myocardial single photon emission computed tomography (SPECT) and Doppler guide wire.
Case ReportAn 84-year-old woman was admitted to hospital with chest pain at rest. She had a history of cerebral infarction, Parkinson's disease and right femoral neck fracture, but no coronary risk factors. Physical examination revealed blood pressure of 92/56 mmHg, and S3 sound and moist rales were audible. An ECG showed ST-segment elevation in leads II, III, aVF and V2-6 (Fig 1) and chest X-ray showed mild cardiomegaly with a cardiothoracic ratio of 55%. The leukocyte count was elevated at 15,700 / l. The serum concentrations of AST (84 IU/L), lactate dehydrogenase (453 IU/L), creatine kinase (CK) (633 IU/L, max 862 IU/L), CK-MB (69 IU/L, max 82 IU/L), C-reactive protein (13.2 mg/dl) and brain natriuretic peptide (1,010 pg/ml) were also elevated. urinalysis revealed Escherichia coli. The concentrations of catecholamines and antibodies of various viruses were normal. Two-dimensional echocardiogram showed apical ballooning akinesis and basal hyperkinesis of the left and right ventricles, 99m Tc-tetrofosmin myocardial SPECT showed severely reduced uptake in the apex (Fig 2) and coronary angiography did not show any organic stenosis other than in a diagonal branch (Fig 3). Left ventriculography showed apical ballooning akinesis and basal hyperkinesis; the ejection fraction (LVEF) was 33% (Fig 4). The pressure gradient between the outflow tract and the apex of the left ventricle was not detected. Right ventriculography also showed apical ballooning akinesis and basal hyperkinesis (Fig 4). The coronary flow velocity pattern and the coronary flow reserve (CFR: ratio of the peak hyperemic to resting coronary flow velocity) were measured with a Doppler guide wire in the middle portion of the left anterior descending artery after administration of intracoronary adenosine triphosphate disodium (Fig 5). The coronary flow velocity pattern showed systolic reverse flow, and rapid diastolic acceleration and there
