Myocardial bridging, a trigger for Takotsubo syndrome.

A 71-year-old female presented with angina and ST elevation in leads V2–V4 on the electrocardiogram. Coronary angiography excluded stenotic lesions. A wrap-around left anterior descending (LAD) with myocardial bridging in the mid-segment was observed (Fig. 1a, d, arrowheads, Video 1). Intravascular ultrasound demonstrated systolic compression of the mid-LAD with a minimum lumen area of 3.06 mm2 (systole) to 5.02 mm2 (diastole) and an echolucent region between the bridged segment and epicardial tissue persisting throughout the cardiac cycle (‘half-moon sign’) (b, e, arrows, Video 2) [1]. Left ventriculography revealed mid-apical ballooning (c, f, arrowheads, Video 3), corresponding with the diagnosis of Takotsubo syndrome. High-sensitive troponin-T (normal ≤30 ng/l) was elevated, reaching a peak (590 ng/l) after 12 h. The patient recalled no trigger. At follow-up she was asymptomatic with normal echocardiography (Video 4).

Fig. 1

Wrap-around LAD with myocardial bridging in the mid segment (a in systole, d in diastole, arrowheads). Intravascular ultrasound demonstrating systolic compression of the mid-LAD with a mean lumen area oscillating from 3.06 mm2 in systole (b) to 5.02 mm2 in diastole (e) and an echolucent region between the bridged coronary segment and epicardial tissue persisting throughout the cardiac cycle, ‘half-moon sign’ (b, e, arrows). Left ventricular angiography revealing mid-apical ballooning with hypercontractility of the basal segments (c, f, arrowheads, in systole and diastole respectively)

Myocardial bridging of a wrap-around LAD has been associated with Takotsubo syndrome [2]. Cardiologists should be alert for this presentation given its implication with worse prognosis [3].

Video 1: Coronary angiography showing myocardial bridging

Video 2: IVUS demonstrating systolic compression of the mid-LAD with a minimum lumen area oscillating from 3.06 mm2 in systole to 5.02 mm2 in diastole and an echolucent region between the bridged coronary segment and epicardial tissue persisting throughout the cardiac cycle (‘half-moon sign’)

Video 3: Left ventricular (LV) angiography revealing typical mid-apical ballooning with hypercontractility of the basal segments

Video 4: Follow-up Echocardiography illustrating restoration of left ventricular function