Apical Takotsubo Syndrome After Elective Stenting of the Left Anterior Descending Artery.

Figures

• 

  Visual Summary. Diagnostic Approach to Chest Pain After Elective Percutaneous Coronary Intervention This algorithm illustrates the differential diagnostic pathway in a patient presenting with chest pain and biomarker elevation after elective left anterior descending artery stenting. Key distinguishing features between type 4a myocardial infarction and Takotsubo syndrome are highlighted, emphasizing the pivotal role of repeat coronary angiography and cardiac magnetic resonance imaging in establishing the correct diagnosis and guiding management. CMR = cardiac magnetic resonance imaging; ECG = electrocardiogram; LGE = late gadolinium enhancement; PCI = percutaneous coronary intervention.

• 

  Figure 1. Electrocardiogram on Admission Electrocardiogram indicated sinus arrhythmia with heart rate of 63 to 69 beats/min, left anterior fascicular block, and right bundle branch block.

• 

  Figure 2. Coronary Angiography Coronary angiography demonstrated (А) a 90% lesion in the obtuse marginal artery, diameter ∼2 mm (arrow), (В) a 90% lesion in the midsegment of the LAD (arrow), and (С) several lesions up to 90% in the right marginal artery, diameter ∼2 mm (arrows). (D) Outcome of balloon angioplasty with stenting of the LAD midsegment; in total, 2 segments were implanted. LAD = left anterior descending artery; OM = obtuse marginal.

• 

  Figure 3. Electrocardiogram During Pain Electrocardiogram showed sinus rhythm at 100 beats/min, ST-segment elevation up to 2 mm in leads I, II, aVL, and V2–V6, and possible ST-segment depression up to 1 mm in lead aVR; interpretation is limited by the underlying bifascicular block.

• 

  Figure 4. Bedside Echocardiography (Cardiac Point-of-Care Ultrasound) During the Acute Phase of Takotsubo Syndrome The upper row shows left ventricle images during systole, the lower row shows images during diastole. (А) Apical 3-chamber view, (В) apical 2-chamber view, and (С) apical 4-chamber view. Ejection fraction was reduced to 47%, and hypokinesis of the left ventricle apex, apical segments of the anterior, inferior walls, and the interventricular septum was observed.

• 

  Figure 5. Contrast-Enhanced CMR on Day 7 After Takotsubo Syndrome Onset (А) Cine image, 2-chamber slice, diastolic phase. (В) Cine image, 2-chamber slice, systolic phase. Hypokinesis of the apical LV segments is observed. (С) CMR with delayed contrast enhancement, LV short axis at the level of apical segments shows no gadolinium uptake in the myocardium. (D) Т2-weighed image. LV short axis at the level of apical segments. Edema of the interventricular septum extending to the LV anterior wall. CMR = cardiac magnetic resonance imaging; LV = left ventricle.

• 

  Figure 6. Electrocardiogram at 6 Weeks After Discharge Sinus arrhythmia, heart rate ∼71 beats/min, bifascicular block, ST-segment in leads V2-V6 is at baseline, negative T waves in chest leads, JT interval within 320 ms.