Tako-tsubo transient left ventricular apical ballooning: is intravascular ultrasound the key to resolve the enigma?

A new cardiac syndrome exhibiting transient left ventricular (LV) apical ballooning has been widely described in Japan. Conversely, there are few series outside Japan.1,2 This syndrome usually affects elderly women, frequently preceded by emotional/physical stress.1,2 These patients present with chest pain, ECG abnormalities, and minimal enzymatic release, mimicking an anterior wall acute coronary syndrome (ACS). LV contractility recovers in several days. Today, the aetiology remains unknown. Systematically, coronary artery disease (CAD) has been ruled out because of the wide akinetic area and absence of significant coronary artery stenosis on angiography. Recently we have published that tako-tsubo patients have a well developed left anterior descending (LAD) coronary artery, suggesting that the akinetic area could be supplied by LAD alone.1

To test the hypothesis that a ruptured coronary plaque could be the underlying aetiology of this syndrome we prospectively performed intravascular ultrasound (IVUS) examination in five consecutive tako-tsubo patients.

METHODS

From May 2003 to February 2004 we identified five patients fulfilling the following criteria: suspected ACS based on chest pain, ECG changes, and enzymatic release; transient LV apical ballooning; absence of stenosis > 50% in all major coronary arteries. All five patients underwent a LV angiographic and coronariographic examination. Mean (SD) time to angiography was 20.2 (12.0) hours (range 5–36 hours) after the onset of symptoms. We measured the length of the LAD in the left lateral projection, from left coronary ostium to its end, by tracing the actual course of the artery. We have termed the most distant spot of the vessel in relation to the left coronary ostium …