Abstract
BACKGROUND: Takotsubo syndrome (TTS) is generally considered a benign condition characterized by transient left ventricular (LV) dysfunction. However, a subset of patients may develop life-threatening complications such as blow-out cardiac rupture. CASE SUMMARY: A 79-year-old woman presented with chest discomfort following a fall and was found to have ST-segment elevation, elevated cardiac biomarkers, and apical akinesis with basal hyperkinesis on echocardiography. Coronary angiography revealed no obstructive lesions, confirming the diagnosis of TTS. Despite stable hemodynamics, she suffered sudden cardiac arrest on day 4. Autopsy revealed LV apical rupture with transmural myocyte loss, contraction band necrosis, interstitial edema, and macrophage infiltration, while the basal segments appeared histologically intact. DISCUSSION: This case underscores the importance of recognizing high-risk features-such as advanced age, female sex, and persistent ST elevation-for early recognition of TTS patients vulnerable to cardiac rupture. Autopsy-based pathological evaluation continues to provide valuable insights into the underlying mechanisms of TTS.