A Unique Case of Transient Midventricular Ballooning: An Atypical Manifestation of Stress-Induced Cardiomyopathy Involving Both Ventricles

Abstract

Stress-induced cardiomyopathy is characterized by reversible systolic dysfunction of the ventricles, usually involving the apical segments. It occurs more commonly in women and is frequently precipitated by emotional or physical stressors. Ever since the first report of typical stress-induced cardiomyopathy-usually known as Takotsubo cardiomyopathy or transient left ventricular apical ballooning syndrome-was issued, variant forms of stress-induced cardiomyopathy have been reported. We describe a patient who presented with typical ischemic chest pain, but who was found to have an atypical form of stress-induced cardiomyopathy: midventricular ballooning syndrome involving both the left and right ventricles. Transthoracic echocardiography and computed tomography were used in this patient.

Stress-Induced Cardiomyopathy: The Role of Echocardiography

“…Transient mid-ventricular ballooning with preserved basal and apical contractility (inverted takotsubo cardiomyopathy) (Fig. 3) has been described 9)19). The morphology of RWMA can be quite different, varying from a small area of akinesis limited to the LV apex to a large area of LV akinesis 20).…”

“…3 ) has been described. 9) 19) The morphology of RWMA can be quite different, varying from a small area of akinesis limited to the LV apex to a large area of LV akinesis. 20) Rare (but serious) complications such as LV free wall rupture and consequent death can occur in a manner similar to that seen in patients with MI.…”

Inverted-Takotsubo Cardiomyopathy in a Patient with Pulmonary Embolism

“…Despite of the poor sensitivity and specificity of ECG abnormalities to diagnose PE and inverse takotsubo cardiomyopathy, there are several frequent features including sinus tachycardia, both complete and incomplete RBBB, S 1 Q 3 T 3 pattern, and ST-segment elevation, non specific T wave abnormalities, respectively 2)4-6). A transthoracic echocardiography (TTE) provide the evidence of PE such as right ventricular systolic dysfunctions and pulmonary hypertensions,4)5) and stress-induced cardiomyopathy may have right ventricular involvement which is associated with more severe impairments in LV systolic functions 14). Thus, it is important to carry out ECG promptly, TTE and coronary angiography based on a high degree of clinical suspicions.…”

“… 2) 4 - 6) A transthoracic echocardiography (TTE) provide the evidence of PE such as right ventricular systolic dysfunctions and pulmonary hypertensions, 4) 5) and stress-induced cardiomyopathy may have right ventricular involvement which is associated with more severe impairments in LV systolic functions. 14) Thus, it is important to carry out ECG promptly, TTE and coronary angiography based on a high degree of clinical suspicions. Further research is needed to elucidate this relationship and different pathophysiological mechanisms for various ventricular morphologies of stress-induced cardiomyopathy.…”

Different Characteristics between Patients with Apical and Non-Apical Subtypes of Stress-Induced Cardiomyopathy

“…Echocardiographic diagnosis of SCM can be made by demonstration of transient left ventricular (LV) apical ballooning with compensatory hyperkinesis of the basal portion (takotsubo cardiomyopathy). More recently, variant forms of SCM involving middle and/or basal segments with sparing of the apex have increasingly been recognized (inverted takotsubo cardiomyopathy) 2-6). However, it is not well known how great portion of patients with SCM present atypical distribution of regional wall motion abnormalities (RWMA) and whether there are different features between the apical and non-apical ballooning syndromes.…”