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creatine phosphokinase elevation. Coronary angiography showed normal coronary arteries without vasospastic diathesis, while the left ventriculogram showed apical ballooning (Figure 1A). Cine magnetic resonance imaging (MRI) also showed apical ballooning (Figure 2A Top), and resting 201Tl myocardial scintigraphy showed fixed perfusion defects at the LV apex, inferior and posterior wall (Figure 2A Bottom). Late gadolinium-enhanced MRI (LGE-MRI) indicated subendocardial late gadolinium enhancement at the apex, which was much smaller than the extent of apical ballooning, without myocardial edema on black-blood T2-weighted imaging (Figure 1B). n 85-year-old previously healthy woman with symptomatic complete atrioventricular block, baseline QRS duration 166 ms, slow ventricular escape rhythm and normal ventricular systolic function underwent successful dualchamber permanent pacemaker implantation with right ventricular (RV) apical (RVA) lead placement. One week later, plasma B-type natriuretic peptide (BNP) increased from 260 to 1,020 pg/ml, and cardiothoracic ratio was increased on chest X-ray (63%>59%). In addition, echocardiography showed new left ventricular (LV) wall motion abnormalities involving the mid and apical segments despite lack of serial change on 12-lead electrocardiogram (ECG) under ventricular pacing, or A

Persistent Left Ventricular Apical Ballooning Induced by Right Ventricular Apical Pacing