Recurrent Transient Apical Cardiomyopathy (Tako-Tsubo-Like Left Ventricular Dysfunction) in a Postmenopausal Female with Diffuse Esophageal Spasms
A 66-year-old woman with a history of AV nodal ablation for atrial fibrillation and severe, diffuse esophageal spasms which required multiple dilations and surgical myectomy had been hospitalized multiple times at a nearby institution with shortness of breath and chest pain. Most of her symptoms had been attributed to esophageal spasms confirmed by manometry. During her first admission, an echocardiogram demonstrated an ejection fraction of 25-30% with apical anterior, inferior and lateral wall akinesis, compatible with Tako-tsubo-like cardiomyopathy. She underwent a coronary angiogram 48 h later with no evidence of obstructive disease and normalization of left ventricular function. Coronary vasospasm was suspected but no provocative testing was performed.\nShe presented six months later to our hospital complaining of severe chest pressure that started abruptly after she became furious at her driver for being late. Her ECG on admission [] displayed a ventricular paced rhythm, with hyperacute T waves and new ST segment elevation in anterior precordial leads; she was given aspirin and started on heparin infusion. Once intravenous infusion of nitroglycerin was initiated, she had resolution of her index symptoms, as well as most of her ECG changes []. She had a minor elevation in her troponin levels. Echocardiogram performed the next morning [] revealed an ejection fraction of 15% with apical ballooning, consistent with Tako-tsubo-like cardiomyopathy. She received supportive management and was started on long acting nitrates and calcium channel blockers with no recurrence of symptoms. On admission day # 5, her left ventricular function was reassessed by echocardiogram and noted to be within normal limits.