Methods:
Baseline investigations showed WBC of 14.9 and urinalysis suggestive of UTI. Her Troponin level and proBNP were reported high (troponin 56 and proBNP of 16, 484). Electrocardiography (EKG) revealed atrial fibrillation with rapid ventricular response, low voltage QRS, poor R wave progression, and non-specific T wave abnormalities. Transthoracic echocardiography reported a mildly dilated left ventricle and new severely reduced systolic left ventricular ejection fraction (LVEF 24%) with moderate diffuse hypokinesia, akinetic left ventricular apex, and severely hypokinetic inferolateroseptal wall, features suggestive of Takotsubo cardiomyopathy (Figure 1). There were no LA or LV clots detected on this echocardiogram, but this study was done without contrast. CT head reported negative for acute intracranial abnormality and the patient was started on IV antibiotics for treatment of sepsis in the setting of a urinary tract infection.
Cardiology was consulted for the newly depressed EF who recommended starting a statin, beta-blockers, and angiotensin-converting enzyme inhibitor (ACEI) if tolerable and a pharmacologic nuclear stress test to evaluate cardiomyopathy further.
The next day, the rapid response team (RRT) was called for hypotension of 66/38 mmHg and chest pain.  EKG revealed atrial fibrillation with rapid ventricular response, right bundle branch pattern (RBBB), and ST elevations in the anterolateral leads suggestive of acute ST-elevation myocardial infarction (Figure no. 2).
The patient was started on inotropic support and was emergently transferred to the cardiac catheterization laboratory.  On coronary catheterization, after placement of a balloon pump for hemodynamic support, a proximal LAD lesion with 100% occlusion and heavy thrombus burden was discovered (Figure 3). Initially, thrombus aspiration using a Pronto Extraction Catheter was attempted which was unsuccessful, but after POBA (percutaneous old balloon angioplasty) of the proximal LAD flow was restored. Post-injection revealed TIMI 3 flow in the LAD with no further underlying LAD disease, but a new 100% occlusion of the proximal LCx was now detected which likely occurred due to clot embolization during PCI to LAD (Figure 4). Again, after a trial of unsuccessful thrombectomy using the Pronto Extraction Catheter, POBA followed by deployment of a DES to the pLCX was performed without any further complications.
.
A repeat transthoracic echocardiogram after PCI revealed an improvement in LVEF from 24% to 45% EF. The patient was eventually weaned off the balloon pump and pressor support after 4 days and was started on beta blockers and angiotensin-converting enzyme inhibitors (ACEI) and clopidogrel along with rivaroxaban and was discharged home after a week with outpatient follow-up at the cardiology clinic.