Apical-to-Mid-Ventricular Phenotypic Shift in Recurrent Takotsubo Syndrome After Minor Trauma

Takotsubo syndrome (TTS) typically presents as classic apical ballooning, but recurrent episodes may manifest a distinct phenotype. Physical trauma is an underappreciated potential trigger for atypical phenotypes.

An 84-year-old woman with prior apical TTS sustained a ground-level fall with blunt chest trauma. Troponin I rose from 1,266 to 5,458 ng/L with new lateral T-wave inversions (aVL). Echocardiography showed mid-ventricular akinesia with a hyperkinetic apex (left ventricular ejection fraction ∼35%). Coronary angiography excluded obstructive disease; left ventriculography confirmed mid-ventricular variant TTS, and cardiac magnetic resonance showed myocardial edema without late gadolinium enhancement. Recurrence developed despite long-term beta-blocker and angiotensin-converting enzyme inhibitor therapy; left ventricular function recovered fully within 4 weeks.

This case provides multimodality imaging documentation of an apical-to-mid-ventricular phenotypic switch in recurrent TTS precipitated by minor trauma.

Maintain high suspicion for recurrent TTS with altered phenotype after falls; serial multimodality imaging is essential; pharmacotherapy does not reliably prevent recurrence, so nonpharmacologic risk reduction is important.