Simultaneous Positron Emission Tomography/Magnetic Resonance Imaging Identifies Sustained Regional Abnormalities in Cardiac Metabolism and Function in Stress-Induced Transient Midventricular Ballooning Syndrome

Abstract

A 70-year-old white woman with a history of hyperlipidemia, hypertension, and former smoking and a family history of premature coronary artery disease presented with acute substernal chest pain. She complained of progressive exertional dyspnea during the preceding weeks and of being under personal stress during this time. Her initial ECG showed ST-segment elevation of a maximum 0.2 mV and a reduced R-wave progression in the anteroseptal leads (V1–3). Her troponin T level was moderately elevated (0.3 ng/mL), with normal creatine kinase (CK) and CK-myocardial band (CK-MB) fraction. Cardiac catheterization was performed and showed angiographically normal epicardial coronary arteries. However, the left ventriculogram demonstrated midventricular dilatation and akinesis with a hypercontractile apex and base compatible with midventricular ballooning syndrome, a variant of Takotsubo cardiomyopathy (TTC) (Figure 1A and 1B and Movie I in the online-only Data Supplement). Transthoracic echocardiographic monitoring during the next couple of days revealed no substantial changes in midventricular akinesis. Six days after the onset of symptoms, …