Takotsubo-Like Syndrome Due to Microvascular Dysfunction in a Transgender Woman Under Gender-Affirming Hormone Therapy

Figures

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  Figure 1. Electrocardiographic Changes Before and After Thrombolysis (A) Pre-thrombolysis electrocardiogram: Twelve-lead electrocardiogram obtained at the referring emergency department before thrombolytic therapy, demonstrating sinus rhythm with acute ST-segment elevation in leads V1 to V2, consistent with an anteroseptal injury pattern. (B) Post-thrombolysis electrocardiogram: Repeat 12-lead electrocardiogram obtained after administration of tenecteplase, showing partial resolution of ST-segment elevation in V1 to V2, with evolving repolarization changes.

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  Figure 2. Admission Electrocardiogram at the Tertiary Care Center Twelve-lead electrocardiogram obtained on admission demonstrating sinus rhythm with left axis deviation, pathological QS complexes in the anteroseptal leads (V1-V4), and diffuse repolarization abnormalities characterized by deep T-wave inversions from V3 to V6, consistent with evolving myocardial electrical changes.

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  Figure 3. Coronary Angiography and Ventriculography Findings Consistent with Takotsubo Syndrome (A) Left anterior descending artery without lesions, right caudal projections. (B) Left circumflex artery without lesions, caudal projection. (C) Right coronary artery, nondominant, without lesions, left anterior oblique projection. (D) Left ventriculography in the diastolic phase demonstrating preserved global left ventricular cavity geometry without segmental collapse. (E) Left ventriculography in the systolic phase revealing apical akinesia with preserved basal contractility, resulting in the characteristic systolic configuration consistent with Takotsubo syndrome. Yellow outlines delineate the left ventricular endocardial silhouette in diastole (D) and systole (E).

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  Figure 4. Apical Dysfunction and Ischemic Late Gadolinium Enhancement on Cardiac MRI Cine magnetic resonance imaging sequences (SSFP) showing 4-chamber images during diastole and systole, indicating impaired contractility in the apical segments (A and B). (C and D) Late gadolinium enhancement sequences, with an ischemic pattern of late gadolinium enhancement in the anterior, septal walls, and apical segments, compatible with myocardial infarction. In addition, hypointense areas in the septal wall, associated with regions of enhancement, are noted, consistent with microvascular obstruction/no-reflow phenomenon. White arrow in A indicates apical impaired contractility during diastole; white arrow in B indicates apical impaired contractility during systole; yellow arrows in C and D indicate hypointense area in the septal wall consistent with MVO.

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  Figure 5. Coronary Computed Tomography Angiography Demonstrating Moderate Coronary Artery Calcification (Agatston Calcium Score = 148) With Calcified Plaques Located in the Proximal Segment of the Left Anterior Descending Coronary Artery, Resulting in Mild Luminal Narrowing (<25%), Consistent With Nonobstructive Coronary Artery Disease (A) Left anterior descending coronary artery. (B) Circumflex coronary artery.