PMC2778463_01
Acute coronary syndrome with angiographically normal coronary arteries and apical ballooning of the left ventricle. (a) Twelve-lead ECG demonstrating ST-segment elevation in anterior leads; (b) normal right coronary artery; (c) normal left coronary artery; (d) contrast left ventriculography in the right anterior oblique projection at end-diastole; (e) end-systole showing apical ballooning and basal hyperkinesia.
CRP2009-351621.001.jpg
PMC2778463_01_CRP2009-351621.001.jpg
fig1
Due to persistent symptoms (about two hours), the woman went to the hospital emergency department, where an electrocardiogram (ECG) revealed ST-segment elevation in the anterior leads (Figure 1(a)). Urgent coronary angiography was performed and revealed no coronary stenosis (Figures 1(b) and 1(c)). However, right anterior oblique ventriculography showed characteristic regional wall-motion abnormalities involving a typical apical ballooning (Figures 1(d)  and 1(e)).
(a) Regional wall-motion abnormality confirmed by transthoracic echocardiography during diastole; (b) systole (arrow); (c) magnetic resonance imaging showing wall motion abnormalities during diastole; (d) systole (arrow); (e) twelve-lead ECG demonstrating resolution of ST-segment elevation, development of T-wave inversion, and prolongation of the QT interval.
CRP2009-351621.002.jpg
PMC2778463_01_CRP2009-351621.002.jpg
fig2
Transthoracic echocardiogram showed an abnormal left ventricle with akinesia of apex, anterolateral segments, and interventricular septum (Figures 2(a)  and 2(b)). Cardiac magnetic resonance imaging confirmed regional wall-motion abnormalities (Figures 2(c)  and 2(d)) and was helpful in excluding delayed hyperenhancement suggestive of myocardial infarction or myocarditis. The ECG at discharge showed prolongation of the Q T interval associated with a persistent ST-segment elevation and subepicardial ischemia (Figure 2(e)).