Left Ventricular Apical Ballooning Syndrome with Extensive Myocardial Late Gadolinium Enhancement: Tako-Tsubo Cardiomyopathy, Perhaps Not as Benign as Previously Thought?

Aim: In patients meeting the criteria for LV apical ballooning syndrome, CMR typically identifies myocardial oedema without Late Gadolinium Enhancement (LGE). However, LGE does not exclude LV apical ballooning syndrome and small necrotic areas can be seen in the acute setting resolving at follow-up. Results: We describe the case of a 61 year-old woman admitted with a 2 h history of retrosternal chest pain. ECG demonstrated Q waves and dynamic ST segment elevation. Cardiac enzymes on admission were elevated. Coronary angiography showed unobstructed coronary arteries. Left ventriculography showed apical ballooning. Cardiac Magnetic Resonance (CMR) revealed antero-septal and anterior akinesia. Myocardial oedema was seen in the septal wall. Late gadolinium enhancement (LGE) was seen in the same territory indicating the presence of necrosis. A follow up CMR scan was performed at 3 months showing a complete resolution of the septal oedema. However, on LGE sequences there was evidence of persistent extensive fibrotic scar located in the septal wall. The size of this fibrotic scar was 20% bigger than on the previous scan. Conclusions: Detection and quantification of a scar is important, as scar tissue on LGE images has been described as a predictor of major adverse cardiac events. Therefore, this case suggests that the spectrum of Tako-tsubo cardiomyopathy may include a more severe variant than previously described. CMR examinations could serve as a useful means to identify severe cases and predict potential complications of this pathology as well as to drive therapeutic decisions.