Transient left ventricular apical ballooning complicated by a mural thrombus and outflow tract obstruction in a patient with pheochromocytoma.

A 53-year-old postmenopausal woman presented at the emergency department shortly after an episode of intense emotional stress. She was experiencing angina-like chest pain. An electrocardiogram (ECG) showed ST-segment elevation in the anterolateral and inferior leads (Fig. 1). Immediate coronary angiography revealed normal coronary arteries. Two-dimensional echocardiography showed extensive mid-ventricular and apical akinesis and a large mural thrombus in the apex (Fig. 2) of the left ventricle (LV). Basal segments of the LV were hyperkinetic, generating a LV outflow tract (LVOT) gradient of 144 mmHg (Fig. 3). The LV ejection fraction (LVEF) was 0.32, in accordance with the Simpson rule. The following hormone levels were highly elevated in the urine: epinephrine, 8,720 (reference range, 0–190); norepinephrine, 7,650 (reference range, 0–620); and dopamine, 8,020 (reference range, 425–2,610). The cardiac enzymes were moderately elevated (peak creatine kinase, 1,690 U/L; and peak troponin I, 2.74 μg/L). Results of serum tests for viral infections were negative. Computed tomography revealed a cystic mass of the left adrenal gland (Fig. 4). The patient was treated with heparin (intravenous), aspirin, a diuretic, and an α-adrenergic blocker. Two weeks later, echocardiography showed normal LV regional systolic function (Fig. 5), absence of the mural thrombus, and no LVOT obstruction. The LVEF was 0.60. Histopathologic examination after surgery confirmed a diagnosis of pheochromocytoma (Fig. 6).