PMC9108163_01
12-lead electrocardiogram obtained at admission, showing sinus tachycardia, T wave inversion in left precordial, inferior and lateral leads, and a prolonged corrected QT.
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F1
T wave inversion in left precordial leads, inferior and lateral leads, and a corrected QT of 487 ms (Figure 1). The chest X-ray was unremarkable.
Transthoracic echocardiogram obtained at admission. (A) Parasternal long axis view showing left ventricle dilation and dilation of aortic root and ascending aorta. (B) Apical four-chamber view revealing left ventricle dilation with reduced ejection fraction due to apical and midventricular akinesia in the septal and lateral walls, and normal right ventricular function. (C) Severe aortic regurgitation in (five-chamber view). (D) Apical two-chamber view showing akinesia of the midventricular and apical segments of the anterior and inferior left ventricular walls.
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F2
The transthoracic echocardiogram revealed severe LV dilation with reduced EF (36%), due to apical and midventricular akinesia; severe AR; dilation of aortic root and ascending aorta (23 mm/m2 and 24 mm/m2 respectively); moderate tricuspid regurgitation; maximal tricuspid regurgitation velocity of 3.3 m/s; and right ventricle with normal dimensions and longitudinal systolic function (Figure 2/Supplementary Video 1).
Coronary angiography and acetylcholine test performed during admission. (A) Coronary angiography in the left anterior oblique view showing normal right coronary artery. (B) Cranial right anterior oblique view showing normal left coronary artery. (C) Cranial right anterior oblique view revealing spasm of both the left anterior descending and circumflex arteries, during an acetylcholine provocative test.
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F3
During cannulation of the left coronary artery, an acetylcholine provocative test was performed, showing spasm of both the LAD and circumflex arteries, accompanied by reproduction of chest pain and ST depression, which completely reverted after intracoronary nitrates administration (Figure 3).