Coronary spasm and myocardial bridging: an elusive pathophysiological mechanism leading to apical ballooning syndrome?

Apical ballooning syndrome or Takotsubo-like cardiomyopathy is an acute syndrome characterized by normal or near-normal coronary arteries, regional wall motion abnormalities that extend beyond a single coronary vascular bed and, often, a precipitating stressor. We observed a case of an elderly lady with Takotsubo-like left ventricular dysfunction in whom both left anterior descending artery and diagonal branch coronary artery reversible spasm and myocardial bridging were demonstrated at the time of acute cardiac catheterization. It is a common observation that a combination of multiple pathophysiological mechanisms may produce a clinically similar picture. We believe that reversible, yet extreme, spasticity elicited at the level of myocardial bridging and involving a territory beyond a single coronary branch may explain in this case a functional phenomenon, namely the Takotsubo-shaped dysfunction of the left ventricle, which is more commonly observed in women with totally normal coronary arteries after exaggerated sympathetic stimulation.