LAUSR

Learning Objectives: Takotsubo cardiomyopathy (TCM), also known as Broken Heart Syndrome, is a transient cardiac disorder that can mimic acute coronary syndrome. It is often precipitated by an emotional or physical stressor. Patients may present with chest pain, dynamic electrocardiogram (ECG) changes, and/or cardiac biomarker elevations. However, coronary arteries are normal and regional wall motion abnormalities of the left ventricle (LV) extending beyond a single coronary distribution classically involve apical ballooning. We present a rare variant of TCM, midventricular ballooning. Methods: A 50-year-old postmenopausal woman with a history of generalized anxiety disorder and attention deficit hyperactivity disorder on methylphenidate underwent an elective abdominal hernia repair with general anesthesia. At the time of incision, early during the surgery, the patient had a brief episode of asystole and hypotension with associated ST-T abnormalities on ECG. Cardiac biomarkers, to include Troponin T levels, were mildly elevated. Echocardiogram at that time showed a dilated LV with systolic dysfunction and severe hypokinesis of the mid to distal anterior, septal, lateral, and inferior walls with sparing of the base and apex. Subsequent cardiac catheterization revealed normal coronary arteries. Left ventriculography (LVG) confirmed mid ventricular ballooning with a hyperdynamic base and apex, consistent with mid-ventricular variant TCM. Results: The patient was started on standard heart failure therapy, to include a beta-blocker and ACE-inhibitor, and recovered uneventfully during her hospitalization. Within two weeks of her diagnosis, the evolving ECG changes returned to baseline. A repeat echocardiogram one month later demonstrated normal left ventricular function without regional wall motion abnormalities. In conclusion, this case portrays a rare variant to a unique diagnosis that has important implications for clinical management and prognosis.