The Shape-Shifting Heart: Recurrent Takotsubo Cardiomyopathy Manifesting as Two Variants in One Patient.

Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy, is a transient left ventricular dysfunction that mimics acute coronary syndrome but typically resolves within weeks. Its recurrence is uncommon, and recurrence with distinct morphologic variants is exceedingly rare. We report a 75-year-old female with peripheral arterial disease, paroxysmal atrial fibrillation, sick sinus syndrome status post pacemaker, and prior apical variant TCM in 2022. She underwent a right lower extremity surgery. Two days postoperatively, she developed acute chest pain and troponin elevation. Echocardiography revealed new left ventricular dysfunction with an ejection fraction (EF) of 35-40% and hypokinesis of the anteroseptal and anterior walls. Coronary angiography demonstrated mild nonobstructive coronary artery disease (CAD). Ventriculography confirmed the mid-ventricular variant of TCM. This contrasted with her prior episode in 2022, when she developed apical ballooning variant TCM with an EF of 25-30% during admission for Escherichia coli bacteremia. In both episodes, her EF normalized on follow-up imaging. This case highlights the protean nature of TCM and the rare phenomenon of recurrence with different morphologic variants. Recognition of variant-specific triggers and long-term surveillance are essential in patients with prior episodes.