Mid-Ventricular Takotsubo Cardiomyopathy and Relevant Abnormalities of the Left Anterior Descending Coronary Artery

Takotsubo cardiomyopathy can be divided in a typical form with apical ballooning (about 85% of cases) and in an atypical form with mid-ventricular (14% of cases) or rare basal ballooning (1%).

In typical apical ballooning spasms, myocardial bridging or recurrent segment (wrap-around) abormalities of the left anterior descending coronary artery have been described.

Far more confusing is mid-ventricular ballooning and its possible abnormalities of the LAD.

Here we describe seven patients with typical mid-ventricular ballooning (3 cases) and anteromedial or inferomedial hypokinesia (4 cases) in concealed mid-ventricular takotsubo cardiomyopathy.

In all seven cases the LAD revealed a rigid straightening of the mid-portion without lumen reduction, but systolic compression of septal (or in one case diagonal) branches.

In rigid straightening course of mid-portion LAD myocardial bridging can be suspected without lumen reduction, but definitely confirmed by cardiac computer tomography.

The relevance of myocardial bridging confirmed by cardiac computer tomography has been described by Federico Migliore and coauthors in 2013. They described in typical apical ballooning myocardial bridging in 76% of cases by cardiac computer tomography. Coronary angiography revealed myocardial bridging in only 40%. A rigid straightening of mid LAD without lumen reduction as indirect sign of myocardial bridging confirmed by cardiac computer tomography is the reason why coronary angiography failed in these cases.

Rigid straightening of mid-LAD with systolic compression of septal or diagonal branches, but without wrap-around left anterior descending coronary artery is possibly the cause of mid-ventricular ballooning or concealed mid-ventricular takotsubo cardiomyopathy.