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Apical ballooning syndrome is a cardiac syndrome typically characterized by transient focal dyskinesia or akinesia of the mid and apical regions of the left ventricle and hyperkinesia of the basal region. The symptoms and signs of the patient mimic myocardial infarction, with chest pain, electrocardiographic changes and elevation of cardiac enzymes but without significant coronary artery disease. The syndrome is frequently preceded by physical or emotional stress. We describe three cases of apical ballooning syndrome diagnosed during 10 days in December 2007 at Landspítali University Hospital Reykjavík.

 

Table I. Different names of Apical ballooning Syndrome.

Fig. 1. Cardiovascular magnetic resonance (CMR) images through the vertical long axis of the left ventricle and the left atrium. Figures 1a and 1b are from case one and show normal thickening of the left ventricular wall at the basis of the heart (to the right of the arrows) but almost no contraction in the apex (to the left of the arrows). Figure 1a shows the heart at the end of diastole and 1b at the end of systole.

Fig. 2. Echocardiogram of the left ventricle of a person with apical ballooning syndrome showing the end of the diastole (A) and end of the systole (B) where the apex shows a typical ballooning. The echocardiogram comes from case 3.

Table II. An overview of patients demographics, symptoms and results of investigations.

Fig. 3. Electrocardiograms (ECG) taken on the day of arrival and on the third day.

3a and 3b show the ECGs from the third patient whose changes are typical for Apical ballooning syndrome. On the day of arrival the ECG shows ST elevations in V₅, V₆ and  aVL, slow R progression. On the third day the ECG shows deep inverted T waves in most leads and QTc is prolonged 463ms.