Aweird focalwall motion abnormality for investigation.

Objectives: CASE: A previously well 62-year-old female presented to the emergency department with central chest pain. Initial electrocardiogram demonstrated sinus rhythm with ST-elevation in V1-V2 and she underwent emergent coronary angiography which demonstrated no obstructive coronary artery stenosis, however left ventriculography demonstrated focal dyskinesis / aneurysm of the mid anterior left ventricular (LV) wall. Contrast enhanced transthoracic echocardiography (TTE) confirmed the appearance and demonstrated a pericardial effusion, raising the suspicion of a contained LV rupture. Cardiacmagnetic resonance (CMR) imaging confirmed the presence of an anterior wall aneurysm with associated oedema on T2 weighted images (Fig 1) however there was no evidence of associated late gadolinium enhancement (LGE) in the region (Fig 1). The patient had been involved in an argument before presenting to hospital and the findings were thought to be most consistent with an atypical Takotsubo cardiomyopathy (TC), and repeat transthoracic echocardiography 1 month later demonstrated complete normalisation of LV contraction. DISCUSSION: TC is a rare syndrome characterized by transient regional systolic dysfunction of the LV, mimickingmyocardial infarction, but in the absence of angiographic evidence of obstructive coronary artery disease or acute plaque rupture. Focal involvement of the myocardium is its rarest form. A large multi-centre study in this population found CMR can accurately identify TC through a typical pattern of LV dysfunction and demonstrates myocardial edema in 81% patients, and no significant LGE in 91%. These findings were consistent with our patient. Interestingly in this study 40% of this patient population also had a pericardial effusion. (Figure Presented).