Left Ventricular Free Wall Rupture in Transient Left Ventricular Apical Ballooning

Abstract

ransient left ventricular apical ballooning [1][2][3][4][5][6] in patients with normal coronary angiography results is characterized by transient left ventricular (LV) dysfunction and chest symptoms, together with electrocardiographic (ECG) changes that mimic those of acute myocardial infarction (AMI). Generally, the prognosis for transient LV apical ballooning is good, because in most patients ventricular function improves with conservative therapy. Nevertheless a very small number die from cardiogenic shock. We report a patient, treated for transient LV apical ballooning, who died from LV free wall rupture. Such an occurrence has not been reported previously in association with transient LV apical ballooning. Case ReportA 79-year-old woman was admitted to hospital in September 2003 with sudden onset of chest pain. Her level of consciousness was clear, her pulse rate was 84 beats/min, and blood pressure was 124/80 mmHg. Auscultation of the heart and lungs was normal. An ECG showed sinus rhythm with ST-segment elevation in leads I, aVL and V1-5, depression in leads III and aVF, and abnormal Q wave in leads V1-4 (Fig 1). Echocardiogram at the time of admission revealed akinesis in the LV apical wall. Laboratory data showed increased creatine kinase concentration (768 IU/L). An acute AMI was suspected, and the patient underwent emergency cardiac catheterization. However, coronary angiography did not reveal a stenotic lesion in any coronary artery (Fig 2A,B) (Fig 2C,D), and the LV ejection fraction was 31%. A diagnosis was subsequently made of transient LV apical ballooning, and she was only treated with diuretics.On the fifth day following admission, another ECG indi-

Left ventricular function after takotsubo is not fully recovered in long-term follow-up: A speckle tracking echocardiography study

“…Cardiac rupture is the most severe and oftentimes fatal complication of TTC, which supports the transmyocardial damage [28,29]. Histopathological findings at the rupture site include myocardial necrosis with hemorrhaging, fused foci of coagulation necrosis and contraction band necrosis, as well as diffuse patchy infarction of myocardial in the surrounding tear area [30][31][32][33]. In myocardial biopsies, intestinal fibrosis, contraction band necrosis and mild cell infiltration have been described [13,32].…”

“…Histopathological findings at the rupture site include myocardial necrosis with hemorrhaging, fused foci of coagulation necrosis and contraction band necrosis, as well as diffuse patchy infarction of myocardial in the surrounding tear area [30][31][32][33]. In myocardial biopsies, intestinal fibrosis, contraction band necrosis and mild cell infiltration have been described [13,32]. Several studies have reported complete recovery of LV systolic function in patients with TTC as analyzed by the LVEF during follow-up [2,34,35].…”

Tako-Tsubo Cardiomyopathy: A Recent Clinical Syndrome Mimicking an Acute Coronary Syndrome

“…Moreover, few patients were described as asymptomatic, often admitted for non cardiac illnesses, and TTC was suspected on electrocardiogram or cardiac biomarkers. Life-threatening initial symptoms are uncommon and out-hospital cardiac arrest due to cardiac rupture has also been very rarely recorded (Akashi et al, 2004;Ohara et al, 2005). However, hemodynamic compromise may occur, related to acute complications such as ventricular tachycardia, ventricular fibrillation, severe congestive heart failure or left ventricular outflow tract obstruction (Valbusa et al, 2008;Prasad et al, 2008).…”

“…This condition is involved in a large proportion of the syndrome mortality rate, as sudden cardiac death due to ventricular fibrillation was estimated to be 4% (Ionescu et al, 2010). Other rare complications have been noted such as pneumothorax or left ventricular rupture (Bielecka-Dabrowa et al, 2010;Matsuoka et al, 2000;Sakai et al, 2005;Ohara et al, 2005). A TTC complicated by a ventricular septal dissection with a concomitant septal performation have been recently reported (Mariscalco et al, 2010).…”

Transient Cardiac Ballooning—The Syndrome

“…Very rarely, episodes of late sudden death due to cardiac rupture have been recorded. 18,19 A recent 4 year follow-up study of 100 patients reported 11.4% recurrence of transient LV dysfunction and a cardiovascular mortality of 6%; mostly related to arrhythmias. 20…”