Transient Compression of Coronary Artery-Left Ventricular Micro-Fistulae by Stunned Myocardium in Takotsubo Syndrome

Figures

• 

  Fig. 1.. Demonstration of a case of mid-apical with apical-tip-sparing ballooning pattern of takotsubo syndrome (TS). An elderly female presented with an acute exacerbation of chronic obstructive pulmonary disease. Electrocardiogram (A) shows sinus rhythm and left bundle branch block. Contrast left ventriculography during diastole (B) and systole (C) reveals a mid-apical with apical-tip-sparing pattern of TS. Contrast echocardiography during diastole (D) and systole (E) confirms the finding of left ventriculography. Left coronary angiography (LCA) in (F) and right coronary angiography (RCA) in (G) show no obstructive coronary artery lesions. Further details of LCA and RCA are described in Figs. 2,3.

• 

  Fig. 2.. Demonstration of left ventriculography and left coronary angiography (LCA) during the index presentation and follow-up after 2 and 53 months. Contrast left ventriculography (A) during diastole and systole reveals a typical mid-apical with apical-tip-sparing pattern of TS during the index presentation. LCA (B) shows that flow in the left anterior descending artery (LAD) and septal branches is poor (yellow question marks). Follow-up left ventriculography (C) and LCA (D) 2 months after the index presentation show complete normalization of the left ventricular function. The LAD flow is normal with septal branches ((D), yellow arrows) and signs of coronary artery-left ventricular micro-fistulae (CALVMF) with mild contrast opacification of the left ventricle ((D), small yellow asterisks) are seen. Follow-up left ventriculography (E) and LCA (F) 53 months after the index presentation show that the left ventricular function is completely normal, and the LCA shows signs of extensive CALVMF with clear contrast opacification of the left ventricle ((F), large yellow asterisk).

• 

  Fig. 3.. Demonstration of left ventriculography and right coronary angiography (RCA) during the index presentation and follow-up after 2 and 53 months. Contrast left ventriculography (A) during diastole and systole reveals a typical mid-apical with apical-tip-sparing pattern of TS during the index presentation. RCA (B) shows the peripheral branches of RCA, the posterior descending artery (PDA), and the posterior left ventricular artery. The small septal branches from the PDA are almost invisible ((B), yellow question marks). Follow-up left ventriculography (C) and RCA (D) 2 months after the index presentation show complete normalization of the left ventricular function. The septal branches from the PDA are clearly seen ((D), yellow arrows) and show certain signs of CALVMF with very mild contrast opacification of the left ventricle ((D), small yellow asterisks). Follow-up left ventriculography (E) and RCA (F) 53 months after the index presentation show that the left ventricular function is completely normal, and signs of CALVMF are clearly seen from the PDA segment ((F), large yellow asterisk) and the septal branches from the PDA are larger ((F), yellow arrows).