[Transient left ventricular apical ballooning with dynamic outflow tract obstruction complicated by persistent hypotension]

The pathogenesis of tako-tsubo syndrome remains, nowadays, unclear: it is likely that the relevance of the different proposed mechanisms differs among specific clinical contexts. In this paper, we describe the case of a 61-year-old woman admitted to the intensive cardiac care unit for pre-syncope and persistent hypotension. Clinical and echocardiographic data were suggestive of tako-tsubo syndrome with severe dynamic left ventricular outflow tract (LVOT) obstruction and severe mitral regurgitation. Coronary angiography was normal. Inotropic agents were not administered, because absolutely contraindicated in the presence of LVOT obstruction: indeed, they may worsen the dynamic gradient with further hemodynamic compromise. The patient was, therefore, initially treated with intravenous fluid infusion and, later on, with beta-blockers; the patient had a regular clinical recovery, with progressive disappearance of ECG and echocardiographic abnormalities. This case confirms that an early echocardiographic diagnosis of LVOT obstruction is essential for therapeutic decision-making, especially in the setting of tako-tsubo syndrome presenting with compromised hemodynamic status.