Left ventricular outflow tract obstruction and Takotsubo syndrome

A 76-year-old woman with a medical history notable for factor V gene mutation (with a previous episode of deep venous thrombosis and pulmonary embolism), arthritis and hypertension, on full-dose aspirin (325mg daily) and lisinopril and hydrochlorothiazide (unknown doses), presented in the emergency room complaining of typical 5/10 chest pain, nausea and diaphoresis. She had spent over 5 h gardening, which was usual for her. She was given aspirin and nitroglycerin, but the chest pain persisted (intensity 2/10). Twelve-lead ECG showed sinus rhythm with ST elevation in leads II, V and VI, and troponin was elevated (2.82 ng/ml). She was taken immediately to the cardiac catheterization lab where she was shown to have normal coronary arteries, with a right dominant system, elevated filling pressures and preserved cardiac output, and no evidence of dissection on the ascending aortogram (Figure 1). The echocardiogram demonstrated left ventricular (LV) regional wall motion abnormalities (Figure 2), raising the suspicion of myocarditis or Takotsubo cardiomyopathy. Cardiac MRI was ordered for further elucidation. The left ventricle showed apical ballooning with hypokinetic apex (Figure 3). Asymmetric hypertrophy of the LV walls was also noted, with mitral valve systolic anterior motion (SAM) and flow acceleration across the LV outflow tract (LVOT)