Cardiac rupture due to Takotsubo syndrome complicated by a myocardial bridge: a case series

Background: Takotsubo syndrome is characterized by transient left ventricular systolic dysfunction, without obstructive coronary artery disease. Myocardial bridge, where a coronary artery courses intramurally, may provoke ischaemia and trigger Takotsubo syndrome. Although both conditions typically have favourable outcomes, we encountered two cases of fatal cardiac rupture in patients with Takotsubo syndrome complicated by myocardial bridge. Case summary: We describe two elderly women who developed cardiac rupture secondary to Takotsubo syndrome with a myocardial bridge in the mid-left anterior descending (LAD) artery. Both presented with chest discomfort and ST-segment elevation suggestive of acute coronary syndrome. Coronary angiography revealed no obstructive lesions but demonstrated systolic compression of a myocardial bridge, while left ventriculography showed apical ballooning with basal hyperkinesis. Both patients experienced circulatory collapse due to pericardial tamponade. One achieved transient stabilization following pericardiocentesis but later died of aspiration pneumonia; the other died despite veno-arterial extracorporeal membrane oxygenation. Discussion: Cardiac rupture is an extremely rare but often fatal complication of Takotsubo syndrome. The combination of a myocardial bridge and a wrap-around LAD artery may amplify apical wall stress and myocardial fragility during catecholamine surges, predisposing to rupture. These cases emphasise the need for careful haemodynamic monitoring in Takotsubo syndrome with myocardial bridging, particularly in elderly women with apical ballooning, as even temporary clinical stability may conceal the risk of imminent cardiac rupture.