Intraventricular obstruction in a patient with tako-tsubo cardiomyopathy

We describe a case of a 70-year-old woman who developed chest pain and shortness of breath not related to a stress. The patient, with history of hypertension, presented T-wave inversion and prolonged QTc interval at admission electrocardiogram, peak troponin I level was normal, and no signs of myocarditis were found. Angiography demonstrated the "apical ballooning" without any obstructive coronary artery disease; on pullback of the pigtail catheter from the left ventricular apex to the basal tract, a 35 mm Hg gradient was observed. The echocardiographic evaluation showed asymmetric septal wall thickening of 19 mm, systolic anterior motion of the anterior mitral leaflet, juxtaposition of the septum to the mitral chordal apparatus, no significant left ventricular outflow tract gradient, moderate-to-severe mitral regurgitation and a pulmonary systolic pressure of 40 mm Hg. Rest (201)tallium myocardial perfusion scintigraphy SPECT showed a perfusion defect in the left ventricular apex. At 1-month echocardiographic and scintigraphic follow-up, left ventricular wall motion and myocardial perfusion returned completely normal. Nine months after the acute event the patient remained asymptomatic. We hypothesize that septal ventricular hypertrophy and intraventricular obstruction could be related to the development of some of the cases of tako-tsubo cardiomyopathy.