Figure 2

Diagnostic evaluation and treatment of a patient with takotsubo cardiomyopathy and severe left ventricular outflow tract (LVOT) obstruction. A 74-year old woman was admitted with ST-segment elevation in the precordial leads and in cardiogenic shock. Panel A-B: Left ventricular angiography shows a typical pattern of ‘apical ballooning’ at systole (panel A) when compared to diastole (panel B). Panel C: Intra-aortic balloon pump counter-pulsation therapy was initiated in the cath-lab. Because of refractory shock, dobutamine (dobu) and norepinephrine (levo) were started at the ICU. Cessation of inotropic therapy after echocardiographic diagnosis of LVOT obstruction resulted in recovery of blood pressure. Panel D: Severe LVOT obstruction was identified on continuous wave Doppler echocardiography (end-systolic pressure gradient 149 mmHg). Panel E: Echocardiography confirming the presence of apical akinesia or ‘apical ballooning’. HR: heart rate (beats per minute); BP: blood pressure (mmHg). The white arrows indicate ‘apical ballooning’; the yellow arrows indicate systolic anterior motion (SAM)-induced mitral regurgitation.