Left Ventricular Ballooning Research Articles

Acute Left Ventricular Ballooning: Tools to Differentiate Hypertrophic Cardiomyopathy with Outflow Obstruction from Neurohumoral Takotsubo Syndrome.

Despite considerable interest in the syndrome of acute left ventricular (LV) ballooning, its pathophysiology has remained ill-defined. In this review, we explore observational data describing two etiologies of acute LV ballooning: neurohumoral classic Takotsubo Syndrome (TTS), and acute severe unrelenting left ventricular outflow tract (LVOT) obstruction in patients with obstructive hypertrophic cardiomyopathy (HCM). We describe the clinical presentation and varying pathophysiology of these presentations, explore how echocardiography and cardiac catheterization may help differentiate between the two etiologies, and detail differences in management. We highlight the significant overlap as well as key differentiating features of these conditions, with the aim to improve diagnostic awareness and accuracy and appropriately tailor therapy.

Syndrome of Reversible Cardiogenic Shock and Left Ventricular Ballooning in Obstructive Hypertrophic Cardiomyopathy.

BackgroundCardiogenic shock from most causes has unfavorable prognosis. Hypertrophic cardiomyopathy (HCM) can uncommonly present with apical ballooning and shock in association with sudden development of severe and unrelenting left ventricular (LV) outflow obstruction. Typical HCM phenotypic features of mild septal thickening, outflow gradients, and distinctive mitral abnormalities differentiate these patients from others with Takotsubo syndrome, who have normal mitral valves and no outflow obstruction.Methods and ResultsWe analyzed 8 patients from our 4 HCM centers with obstructive HCM and abrupt presentation of cardiogenic shock with LV ballooning, and 6 cases reported in literature. Of 14 patients, 10 (71%) were women, aged 66±9 years, presenting with acute symptoms: LV ballooning; depressed ejection fraction (25±5%); refractory systemic hypotension; marked LV outflow tract obstruction (peak gradient, 94±28 mm Hg); and elevated troponin, but absence of atherosclerotic coronary disease. Shock was managed with intravenous administration of phenylephrine (n=6), norepinephrine (n=6), β‐blocker (n=7), and vasopressin (n=1). Mechanical circulatory support was required in 8, including intra‐aortic balloon pump (n=4), venoarterial extracorporeal membrane oxygenation (n=3), and Impella and Tandem Heart in 1 each. In refractory shock, urgent relief of obstruction by myectomy was performed in 5, and alcohol ablation in 1. All patients survived their critical illness, with full recovery of systolic function.ConclusionsWhen cardiogenic shock and LV ballooning occur in obstructive HCM, they are marked by distinctive anatomic and physiologic features. Relief of obstruction with targeted pharmacotherapy, mechanical circulatory support, and myectomy, when necessary for refractory shock, may lead to survival and normalization of systolic function.

STRESS AND SHOCK: CASE OF MECHANICAL CIRCULATORY SUPPORT IN TOXIC SHOCK

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Sepsis may induce stress-induced cardiomyopathy by increased catecholamines. Although reversible, In severe cases this may lead to ventricular arrhythmias, thromboembolism, and cardiogenic shock. There is increased hospital mortality with age >80, black race, and presence of multi organ failure. CASE PRESENTATION: 52 yo black male with unknown medical history presents with belligerent behavior and shortness of breath. He was noted to be febrile to 108F, hypotensive with MAPs in the 40s, tachycardic to 140s, and hypoxic to 79% on room air. Labs significant for WBC 1, Cr 4.2, lactic acid 11.7, CK 2407, Troponin 0.104. ABG showed pH 7.19, pCO2 54, pO2 48, FiO2 100%. Chest xray showed bilateral interstitial and airspace opacities. Patient was intubated for hypoxic and hypercapnic respiratory failure and started on norepinephrine, vasopressin, and epinephrine with 5L fluid bolus and stress dose steroids. TTE demonstrated left ventricle apical and mid wall segment akinesis with left ventricular ballooning. VA-ECMO emergently initiated for ARDS management and Impella was placed for cardiogenic shock secondary to sepsis-induced Takotsubo cardiomyopathy. Sputum cultures returned positive for MRSA and Streptococcus pyogenes. Antibiotics changed to vancomycin, zosyn, azithromycin, cefepime, and clindamycin to account for toxic shock. Hospital course was complicated by development of pancytopenia requiring use of granix, atrial fibrillation with rapid ventricular rate requiring emergent cardioversion, and renal failure requiring CRRT. Impella was removed on the sixth hospital day and the patient started on dobutamine. Patient eventually developed critical limb ischemia in all four extremities with need for bilateral hand and hip disarticulations. On the ninth hospital day, the patient was transitioned to comfort care and passed away. DISCUSSION: In the case above, toxic and septic shock caused stress-induced cardiomyopathy that required VA-ECMO and Impella. In the adult population, VA-ECMO has not been widely used in the treatment of refractory shock and outcomes with VV-ECMO have been better than VA-ECMO. This is likely due to VA-ECMO's use in profound hypoperfusion and higher incidence of neurological complications, renal failure, and limb ischemia. The addition of Impella helps unload the left ventricle and helps with EMCO weaning. CONCLUSIONS: Studies have found that better outcomes were associated with door-to-ECMO times of ≤96 hours, Gram-positive sepsis, and pneumonia rather than primary bloodstream infections. Though our patient met all of these criteria, his case still resulted in poor outcomes. REFERENCE #1: Cheng A, Sun HY, Tsai MS, Ko WJ, Tsai PR, Hu FC, Chen YC, Chang SC. Predictors of survival in adults undergoing extracorporeal membrane oxygenation with severe infections. The Journal of thoracic and cardiovascular surgery. 2016 Dec 1;152(6):1526-36. REFERENCE #2: Nabzdyk CS, Couture EJ, Shelton K, Cudemus G, Bittner EA. Sepsis induced cardiomyopathy: Pathophysiology and use of mechanical circulatory support for refractory shock. Journal of critical care. 2019 Dec 1;54:228-34. REFERENCE #3: Schmitz, M., Roux, X., Huttner, B. et al. Streptococcal toxic shock syndrome in the intensive care unit. Ann. Intensive Care 8, 88 (2018). https://doi.org/10.1186/s13613-018-0438-y DISCLOSURES: No relevant relationships by Debapria Das, source=Web Response No relevant relationships by Abigail Go, source=Web Response No relevant relationships by Daniele Valentini, source=Web Response

Stress cardiomyopathy induced during dobutamine stress echocardiography.

Background:Catecholamines play a central role in pathogenesis of stress cardiomyopathy (SC). We aimed to review the clinical characteristics, procedural details and outcomes of patients with SC during dobutamine stress echocardiography (DSE).Methods/Results:A total of 20 adults [age 64±15 years, 80% women, 67% hypertension, 20% diabetes, 33% hypercholesterolemia, 19% chronic kidney disease, 13% known anxiety disorder] with SC during DSE were identified from local digital archives of our laboratory (n=3) or reports in English literature (n=17). Indication for DSE was suspected coronary artery disease (CAD) in all patients. Left ventricular (LV) ejection fraction was normal at baseline. SC developed at a blood pressure of 154±47/86±24 mmHg, heart rate of 130±17 bpm (88±10% predicted maximum) and peak rate-pressure product of 20559±3898 mmHg*bpm. ST segment elevation was seen in 65%. SC occurred at peak dobutamine infusion rate of 38±6 μg/kg/min in 85% and during recovery in 15%. Atropine [0.7±0.6 (0.25-2) mg] was given to 7 patients. LV ejection fraction dropped to 30±6% with apical (40%), apical and mid (45%) or basal and mid (10%) circumferential LV ballooning. One patient (5%) had a mixed pattern of wall motion abnormality. LV outflow tract obstruction developed in 15%. Major adverse cardiac events occurred in 7 (35%) and included death (n=1), congestive heart failure (n=2), hypotension (n=3) and atrial fibrillation with heart failure (n=1). At a mean follow up duration of 19±19 days, complete or partial recovery of LV wall motion abnormality was seen in 18 and 1 patient, respectively.Conclusion:SC uncommonly occurs during DSE. However, death and other adverse events (hypotension, heart failure and atrial fibrillation) may occur and require urgent attention. Once managed, complete recovery is expected in most patients.

Spontaneous coronary artery dissection and takotsubo syndrome: An often overlooked association; review.

Spontaneous coronary artery dissection (SCAD) and takotsubo syndrome (TS) are two cardiovascular syndromes with predilection for women. Both conditions may be preceded by an emotional stress or, for the affected individual, an unusual severe physical exercise. "Restitution ad integrum" occurs in most cases suffering from SCAD or TS with complete angiographic resolution of the dissected vessel and left ventricular dysfunction respectively. Recently, many cases, which were initially diagnosed as TS because of typical left ventricular ballooning pattern showed to have SCAD, have been reported; these cases were deemed to be "SCAD misdiagnosed as TS". The left ventricular wall motion abnormality has been attributed to the ischemia caused by SCAD-affected coronary vessel especially in the left anterior descending artery (LAD) with "wrap-around course". However, the left ventricular ballooning pattern have occurred in patients with SCAD in non-long-wrap-around LAD and SCAD in other coronary branches where coronary ischemia on its own cannot explain the left ventricular ballooning. In this review, sufficient data supporting the evidence for the possibility of coexistence of SCAD and TS is provided. Misdiagnosis of the association of the two conditions may result in mismanagement of the patient with undesirable consequences. Furthermore, the causal links between SCAD and TS is discussed.

A type of anteroseptal left ventricular ballooning in apatient with Takotsubo cardiomyopathy.

A type of anteroseptal left ventricular ballooning in apatient with Takotsubo cardiomyopathy.

Pathophysiology of Takotsubo Syndrome

Originally described by Japanese authors in the 1990s, Takotsubo syndrome (TTS) generally presents as an acute myocardial infarction characterized by severe left ventricular dysfunction. TTS, however, differs from an acute coronary syndrome because patients have generally a normal coronary angiogram and left ventricular dysfunction, which extends beyond the territory subtended by a single coronary artery and recovers within days or weeks. The prognosis was initially thought to be benign, but subsequent studies have demonstrated that both short-term mortality and long-term mortality are higher than previously recognized. Indeed, mortality reported during the acute phase in hospitalized patients is ≈4% to 5%, a figure comparable to that of ST-segment-elevation myocardial infarction in the era of primary percutaneous coronary interventions. Despite extensive research, the cause and pathogenesis of TTS remain incompletely understood. The aim of the present review is to discuss the pathophysiology of TTS with particular emphasis on the role of the central and autonomic nervous systems. Different emotional or psychological stressors have been identified to precede the onset of TTS. The anatomic structures that mediate the stress response are found in both the central and autonomic nervous systems. Acute stressors induce brain activation, increasing bioavailability of cortisol and catecholamine. Both circulating epinephrine and norepinephrine released from adrenal medullary chromaffin cells and norepinephrine released locally from sympathetic nerve terminals are significantly increased in the acute phase of TTS. This catecholamine surge leads, through multiple mechanisms, that is, direct catecholamine toxicity, adrenoceptor-mediated damage, epicardial and microvascular coronary vasoconstriction and/or spasm, and increased cardiac workload, to myocardial damage, which has a functional counterpart of transient apical left ventricular ballooning. The relative preponderance among postmenopausal women suggests that estrogen deprivation may play a facilitating role, probably mediated by endothelial dysfunction. Despite the substantial improvement in our understanding of the pathophysiology of TTS, a number of knowledge gaps remain.

The natural history of takotsubo syndrome: a two-year follow-up study with myocardial sympathetic and perfusion G-SPECT imaging.

To investigate changes in sympathetic activity, perfusion, and left ventricular (LV) functionality in takotsubo cardiomyopathy (TTC) patients from onset (T0) to post-onset conditions at 1month (T1), 1-2 years (T2, T3). Twenty-two patients (70 ± 11 years) underwent serial gated single photon emission tomography (G-SPECT) studies with 123I-mIBG and 99mTc-Sestamibi. Statistics were performed using ANOVA/Sheffé post-hoc, correlation test, and receiver operating characteristic (ROC) curve analysis (p < 0.05). Patients presented at T0 with LV ballooning and reduced early-late mIBG uptake (95%, 100%), left ventricular ejection fraction (LVEF)G-SPECT (86%) and perfusion (77 %). Adrenergic dysfunction was greater in apex, it overlaps with contractile impairment, and both were more severe than perfusion defect. During follow-up, LVEFG-SPECT, contractility, and perfusion were normal, while 82% and 90% of patients at T1 and 50% at T2 and T3 continued to show a reduced apical early-late mIBG distribution. These patients presented at T0-T1 with greater impairment of adrenergic function, contractility, and perfusion. A relationship was present within innervation and both perfusion and contractile parameters at T0 and T1, and between the extent of adrenergic defect at T3 and both the defect extent and age at T0 (cut-off point 42.5%, 72 years). Outcome for TTC is not limited to a reversible contractile and perfusion abnormalities, but it includes residual adrenergic dysfunction, depending on the level of adrenergic impairment and age of patients at onset. The number of patients, as well as degree of perfusion abnormalities were found to be higher than those previously reported possibly depending on the time-interval between hospital admission and perfusion scan.

Factors Suggestive of Cardiac Complications in Takotsubo Cardiomyopathy: Multicenter Study

Background: Takotsubo cardiomyopathy (TM) is characterized by acute and transient myocardial segmental wall motion abnormality especially at the apical area with chest pain mimicking acute myocardial infarction. TM is generally accepted to show good prognosis, however, we experience some cases with severe cardiac complications including acute heart failure (AHF), cardiac rupture and ventricular arrhythmias. We characterized TM patients developing these complications. Methods and results: Eighty three patients were studied. Patients with AHF, cardiac rupture, ventricular arrhythmias and death due to cardiac complications (CC group, n = 29) were compared with other patients without cardiac complications (NC group, n = 54). There was no difference between the two groups in age, sex, and coronary risk factors. Common primary symptom in the CC group was dyspnea but was chest pain in NC group. A preceding emotional stress was a common trigger for CC group. Left ventriculography showed significantly decreased ejection fraction in the CC group (39.7 ± 10.2% vs. 53.9 ± 14.1%, p = 0.002). Similarly, more than two segments of impaired left ventricular wall motion was a significant predictor of severe cardiac complications. Conclusions: Clinical onset with dyspnea and extended area of left ventricular ballooning are signs predicting cardiac complications in TM. Received Date: March 29, 2016 Accepted Date: May 02, 2016 Published Date: May 12, 2016 Citation: Isobe, M., et al. Factors Suggestive of Cardiac Complications in Takotsubo Cardiomyopathy: Multicenter Study. (2016) J Heart Cardiol 2(2): 16. Open Access Review Article

ECG in patients with tako tsubo cardiomyopathy

Takotsubo cardiomyopathy, also known as transient left ventricular ballooning and stress myocardiopathy, has been diagnosed increasingly more over the last decade. The takotsubo syndrome mimics acute myocardial infarction in symptoms and in electrocardiographic findings. There are two major types of takotsubo cardiomyopathy: the classical type with left ventricular apical ballooning and a type with midventricular ballooning. Both types show different electrocardiographic patterns at presentation. The present article describes classical electrocardiographic findings of the acute and subacute phases of takotsubo cardiomyopathy.

“Ballooning” patterns in takotsubo cardiomyopathy reflect different clinical backgrounds and outcomes: a BOREAS-TCM study

Whether different patterns of ventricular ballooning in takotsubo cardiomyopathy (TCM) reflect differences in trigger mechanisms or clinical outcomes is unclear. Here we examined differences in the clinical characteristics of typical and atypical forms of TCM. TCM patients (n = 251) in the BOREAS Registry were enrolled for comparison of TCM with apical ballooning (type A, n = 217) and TCM with non-apical ballooning (type non-A, n = 34). The percentage of females was significantly lower in the type non-A group (58.8 vs. 75.6 %), while other demographic parameters and triggers of TCM were similar in the two groups. Rate of mid-ventricular obstruction (MVO) was lower (2.9 vs. 14.3 %) in the type non-A group than in the type A group, though left ventricular ejection fractions in the two groups were comparable. During a follow-up period of 2.6 ± 2.8 years, TCM recurred in 2.9 % of the patients and cardiac death occurred in 4.0 %. Cox proportional hazard analysis indicated that body mass index (hazard ratio [HR]: 0.75, 95 % confidence interval [CI] 0.54-0.99) and MVO (HR: 14.71, CI 1.87-304.66) were determinants of TCM recurrence and that advanced age (HR: 1.09, CI 1.02-1.17) and cardiogenic shock (HR: 4.27, CI 1.07-18.93) were significantly associated with cardiac death. In conclusion, approximately 20 % of TCM patients show non-apical left ventricular ballooning, and female sex and MVO are less frequent in this type than in apical ballooning type TCM. Low body mass index and MVO are risk factors of recurrence, and advanced age and cardiogenic shock are risk factors of cardiac death in TCM.

Takotsubo cardiomyopathy in pregnancy

Abstract We have described a rare case of Takotsubo cardiomyopathy in pregnancy, which is presented with cardiac arrest (ventricular fibrillation) at onset. In this case, the transient left ventricular ballooning in absence of coronary artery disease, produced a severe impairment of cardiac function with typical echocardiographic and electrocardiographic findings. There were complications in the form of ventricular fibrillation, with recurrence due to possible Takotsubo cardiomyopathy and new malignant heart rhythm disorder that increases the mortality rate compared with the first attack of Takotsubo cardiomyopathy. Due to presented symptoms the patient has opted for the implantation of cardioverter defibrillator.

Increased ventricular wall stress and late gadolinium enhancement in Takotsubo cardiomyopathy

Left ventricular (LV) transient ballooning or the so-called Takotsubo syndrome is a rare disease predominantly occurring in elderly females subsequently to emotional stress disorders. Patients present with acute chest pain, occasionally dyspnea and exhibit regional LV wall motion abnormalities, bearing resemblance to myocardial infarction, although relevant coronary obstruction is not present [ [1] Hurst R.T. Prasad A. Askew 3rd, J.W. Sengupta P.P. Tajik A.J. Takotsubo cardiomyopathy: a unique cardiomyopathy with variable ventricular morphology. JACC Cardiovasc Imaging. 2010; 3: 641-649 Abstract Full Text Full Text PDF PubMed Scopus (181) Google Scholar ]. Besides the typical and eponymous apical type of LV ballooning, biventricular, midventricular and rare basal types have also been described [ [2] Eitel I. von Knobelsdorff-Brenkenhoff F. Bernhardt P. et al. Clinical characteristics and cardiovascular magnetic resonance findings in stress (Takotsubo) cardiomyopathy. JAMA. 2011; 306: 277-286 Crossref PubMed Scopus (568) Google Scholar ]. Usually, complaints and cardiac impairment are of transient nature and completely reversible. Although a preceding excessive catecholamine liberation during distress has been assumed, causes are not yet really known and pathophysiological mechanisms are still discussed controversially. Due to increased cardiac load and distending forces, it can be assumed that ventricular wall stress is increased. Patients with Takotsubo syndrome frequently have increased levels of plasma brain natriuretic peptide (BNP). BNP correlates with increased ventricular wall stress [ [3] Alter P. Rupp H. Rominger M.B. et al. B-type natriuretic peptide and wall stress in dilated human heart. Mol Cell Biochem. 2008; 314: 179-191 Crossref PubMed Scopus (45) Google Scholar ]. Cardiac magnetic resonance (CMR) imaging favorably allows assessment of cardiac function, mass and myocardial morphology including late gadolinium enhancement (LGE). Thus, it is hypothesized the need to evaluate LV wall stress based on CMR measurements in Takotsubo cardiomyopathy.

Stress-Induced Hyperviscosity in the Pathophysiology of Takotsubo Cardiomyopathy

Takotsubo cardiomyopathy (TC) is characterized by transient hypokinesis of the left ventricular apex or midventricular segments with coronary arteries without significant stenosis. It is often associated with emotional or physical stress; however, its pathophysiology is still unclear. In the present study, we analyzed the alterations in blood viscosity and markers of endothelial damage induced by sympathetic stimulation in patients with previous TC. Seventeen women (mean age 71 years) with previous TC, included and investigated in the TC Tuscany Registry, were compared to a control group of 8 age- and risk factor-matched women with chest pain and coronary arteries free of stenosis. All subjects underwent the cold pressor test (CPT). Before and after the CPT, the hemorheologic parameters (whole blood viscosity at 0.512 s(-1) and 94.5 s(-1), plasma viscosity, erythrocyte deformability index, and erythrocyte aggregation), catecholamines, plasminogen activator inhibitor-1 (PAI-1), and von Willebrand factor levels were assessed. The patients with TC had significantly greater baseline PAI-1 levels (p <0.01) and lower erythrocyte deformability index values (p <0.01). After CPT, both the patients with TC and the controls had a significant increase in several hemorheologic parameters, catecholamines, and von Willebrand factor levels and a decrease in erythrocyte deformability index. However, the PAI-1 levels were significantly increased only in the patients with TC. Compared to the controls, the patients with TC had significantly greater values of whole blood viscosity at 94.5 s(-1) (p <0.05), PAI-1 (p <0.01), von Willebrand factor (p <0.05) and lower erythrocyte deformability index values (p <0.01) after CPT. In conclusion, the results of the present study suggest that in patients with TC, the alterations in erythrocyte membranes and endothelial integrity induced by catecholaminergic storm could determine microvascular hypoperfusion, possibly favoring the occurrence of left ventricular ballooning.

Cardiac Magnetic Resonance Imaging in the Diagnosis of Anterolateral Left Ventricular Ballooning, a Variant of Classic Takotsubo Cardiomyopathy

Transient left ventricular apical ballooning syndrome is characterized by transient akinesis of the left ventricular apex with basal wall hyperkinesis; this is also known as Takotsubo cardiomyopathy. There are three distinct contractile LV patterns described in the literature: apical, midventricular, and basal ballooning. The apical ballooning pattern is the most frequent pattern. We describe the case of a transient anterolateral left ventricular ballooning fulfilling the definition of Takotsubo cardiomyopathy except for the contractile LV pattern. The diagnosis was supported by cardiac magnetic resonance imaging and by the fact that the anterolateral ballooning resolved completely after 6 weeks.

Atypical "mid-ventricular" Tako-tsubo cardiomyopathy in a patient suffering from posttraumatic stress disorder: A case report

The syndrome of "left ventricular ballooning" summarizes an acute onset of transient extensive akinesia of several segments (apical, mid-ventricular) of the left ventricle, without significant lesions on the coronary angiogram, accompanied by chest symptoms, electrocardiographic changes, and limited release of cardiac markers disproportionate to the extent of akinesia. Initially, the vast majority of cases has been reported among Japanese population. Emotional or physical stress or other preceding triggering factors might play a key role in this reversible form of cardiomyopathy, but the precise etiology remains unknown. We describe a case of a 52-year-old woman with posttraumatic stress disorder after cerebral bleeding presenting with an atypical form of left ventricular ballooning ("midventricular ballooning") syndrome.

Stress cardiomyopathy: transient basal ballooning

Stress cardiomyopathy is a reversible left ventricular dysfunction triggered by emotional stress. We describe a variant of transient left ventricular ballooning in a patient in which basal and midventricular segments are affected. This confirms that there is not just one ventricular dysfunction pattern in Takotsubo cardiomyopathy. The involvement of only the basal and midventricle segments is an intriguing observation with no clear explanation; furthermore, there are no predictive factors for the differently sited wall motion abnormalities.

Cardiogenic shock with basal transient left ventricular ballooning (Takotsubo-like cardiomyopathy) as first presentation of pheochromocytoma

Pheochromocytoma is a rare tumor that produces a distant effect by secretion of catecholamines. This tumor usually presents with hypertension and palpitations but it may also cause cardiogenic shock because of catecholamine-induced myocardial dysfunction. We describe a rare case of Takotsubo-like cardiomyopathy as first manifestation of pheochromocytoma with an unusual onset characterized by severe hypotension and transient basal left ventricular ballooning ('inverted' Takotsubo-like cardiomyopathy).

A case of inverted Takotsubo cardiomyopathy with mid left ventricular and apical right ventricular ballooning

A case of inverted Takotsubo cardiomyopathy with mid left ventricular and apical right ventricular ballooning

Takotsubo Cardiomyopathy

A 62-year old woman presented to our institute with dyspnea and hypotension. The electrocardiogram showed extensive ST elevation in V1-V6, with a negative T wave in leads II, III, and aVF. The troponin T concentration was 0.83 ng/mL (upper normal limit, 0.1 ng/mL). An echocardiography showed a significantly depressed left ventricular (LV) function with extensive akinesis and dyskinesis of all apical and midventricular segments, sparing the basal segments, which were contracting vigorously. The patient had an estimated LV ejection fraction of 0.35. On the basis of the typical shape of the dysfunctioning LV, the fact that the extensive wall motion abnormalities did not follow a coronary distribution pattern, and the coronary arteries were normal on angiography despite the presence of LV angiography of typical apical ballooning (Fig 1) with compensatory basal hyperkinesis, Takotsubo syndrome was diagnosed (arrows). After 2 days of supportive measures, the patient's status improved clinically, the ST elevation turned to a normal pattern, and the echocardiography showed normalization of myocardium function. The patient was discharged 2 days later. The syndrome is also known as “acute left ventricular ballooning,” “transient apical ballooning,” “ampulla cardiomyopathy,” “broken-heart syndrome,” or “human stress cardiomyopathy,” because stress has been implicated in its pathophysiology. Enhanced awareness may lead to increasing recognition of this new nosological entity as a possible complication of cardiac operations.