[A case of ballooning syndrome with atypical anterior localization]

A 59-year-old female patient was admitted for chest pain correlated with an intense emotional stress, negative anterior T-waves and an increase in troponin I levels. The anterior left ventricular wall showed a dyskinetic pattern at echocardiography. Coronary angiography documented normal coronary arteries with the exception of a slight concentric focal narrowing of the ostium of the left anterior descending coronary artery. Echocardiography at 30 days documented normalization of left ventricular wall motion, and a stress test at 90 days, driven by episodes of atypical chest pain, reproduced the symptoms with non-significant electrocardiographic modifications. Coronary angiography confirmed the normal left ventricular wall motion and the persistence of the slight ostial narrowing of the left anterior descending coronary artery. Intravascular ultrasound demonstrated the absence of atheromatous disease of the left anterior descending coronary artery including the ostium. The reported case may be considered as a variant of the apical ballooning syndrome, an acute cardiomyopathy triggered by an intense emotional stress, with transitory wall motion anomalies and angiographically normal coronary arteries. The present case is peculiar for the localization of wall motion abnormalities and for the intracoronary ultrasound documentation of complete absence of coronary atheromatosis despite a suspected minor lesion of the left anterior descending coronary artery.