Blow-Out Cardiac Rupture Caused by Takotsubo Syndrome

Figure 1. Serial Changes of 12-Lead ECG Findings During Hospitalization (A) The 12-lead ECG on admission (day 0) showed sinus rhythm with ST-segment elevation in leads I, II, aVL, aVF, and V2 to V6, along with a prolonged QTc interval (494 ms). Serial ECGs obtained on day 0 (A), day 1 (B), day 2 (C), and day 3 (D) continued to demonstrate ST-segment elevation in I, Ⅱ, aVL, aVF, and V2 to V6, although the elevations slightly attenuated over time. ECG = electrocardiogram; QTc = heart rate–corrected QT interval.

Figure 2. Findings From TTE, CAG, and LVG on Admission (A and B) Parasternal long-axis views on TTE during diastole (A) and systole (B) revealed akinesis of the LV apex with hyperkinesis of the basal segments. No pericardial effusion was observed. (C and D) CAG demonstrated no significant stenosis in the right (C) or left (D) coronary arteries. (E and F) LVG images (LAO view) during diastole (E) and systole (F) show the LV cavity outlined by a white dotted line. Akinesis of the mid-to-apical segments with preserved basal hyperkinesis was noted. CAG = coronary angiography; LV = left ventricle; LVG = left ventriculography; TTE = transthoracic echocardiography.

Figure 3. Pathologic Findings of the Autopsied Heart (A) Gross examination revealed a rupture site at the apical lateral region of the LV, indicated by yellow arrowheads. Approximately 170 mL of blood was found in the pericardial cavity. (B and C) Gross transverse sections of the heart at the basal (upper section in B) and apical (lower section in B) levels. A high-power magnification view of the white rectangular area in (B) is shown in (C). Yellow arrowheads indicate the rupture site in the apicolateral region. (D to F) Microscopic images (H&E staining) of the areas outlined by white rectangles in (B and C). A fresh thrombus (Th) is visible near the rupture site in the LV apex. (G to I) High-power views of the black rectangular fields in (D to F), respectively. Marked myocyte loss, degeneration, and atrophy, along with prominent interstitial edema, are evident in the apical region, particularly at the rupture site (D and E, G and H). In contrast, the basal LV segments (F and I) show minimal histological evidence of myocardial injury. The average myocyte diameter in the apical region was 12.85 μm (11.18–15.80), compared to 19.20 μm (16.40–20.63) in the basal region (P < 0.001 by…

Figure 4. Microscopic Findings of the Apical Area Near the LV Rupture Site Representative high-power images of the LV apex are shown H&E (A), MT staining (B), and immunohistochemistry for CD3 (C), CD68 (D), CD163 (E), and CD79a (F). Atrophic and lost myocytes, interstitial edema, and infiltration of inflammatory cells were observed. Myocardial interstitial fibrosis was minimal. Immunohistochemistry revealed prominent infiltration of CD68+ (D) and CD163+ macrophages (E) surrounding damaged myocytes. Only minimal aggregation of T and B lymphocytes was detected (C and F). Black bars represent 100 μm. CD = cluster of differentiation; H&E = hematoxylin and eosin; LV = left ventricle; MT = Masson trichrome.