Takotsubo cardiomyopathy complicated with apical thrombus formation on first day of the illness: a case report and literature review

Abstract

BackgroundTakotsubo cardiomyopathy is characterized by transient systolic dysfunction of the apical and mid segments of the left ventricle in the absence of obstructive coronary artery disease. Intraventricular thrombus formation is a rare complication of Takotsubo cardiomyopathy and current data almost exclusively consists of isolated case reports and a few case series. Here we describe a case of Takotsubo cardiomyopathy with formation of an apical thrombus within 24 h of symptom onset, which has been reported in the literature only once previously, to the best of our knowledge. We have reviewed the available literature that may aid clinicians in their approach to the condition, since no published guidelines are available.Case presentationA 68-year-old Sri Lankan female presented to a local hospital with chest pain. Electrocardiogram (ECG) showed ST elevation, and antiplatelets, intravenous streptokinase and a high dose statin were administered. Despite this ST elevation persisted; however the coronary angiogram was negative for obstructive coronary artery disease. Echocardiogram revealed hypokinesia of the mid and apical segments of the left ventricle with typical apical ballooning and a sizable apical thrombus. She had recently had a viral infection and was also emotionally distressed as her sister was recently diagnosed with a terminal cancer. A diagnosis of Takotsubo cardiomyopathy was made and anticoagulation was started with heparin and warfarin. The follow up echocardiogram performed 1 week later revealed a small persistent thrombus, which had completely resolved at 3 weeks.ConclusionThough severe systolic dysfunction is observed in almost all the patients with Takotsubo cardiomyopathy, intraventricular thrombus formation on the first day of the illness is rare. The possibility of underdiagnosis of thrombus can be prevented by early echocardiogram in Takotsubo cardiomyopathy. The majority of reports found in the literature review were of cases that had formed an intraventriclar thrombus within the first 2 weeks, emphasizing the importance of follow up echocardiography at least 2 weeks later. The management of a left ventricular thrombus in Takotsubo cardiomyopathy is controversial and in most cases warfarin and heparin were used for a short duration.Electronic supplementary materialThe online version of this article (doi:10.1186/s12872-017-0616-0) contains supplementary material, which is available to authorized users.

Left Ventricular Thrombi and Embolic Events in Takotsubo Syndrome despite Therapeutic Anticoagulation

“…This case series and the published cases listed in Table 2 demonstrate that therapeutic anticoagulation in TTS-related LV thrombi may not completely protect from embolic events in every case. It has been recommended that patients with TTS-related ventricular thrombi should be treated with anticoagulant therapy for 3 months, since usually the wall motion abnormality resolves within this period of time [7, 10, 11]. This recommendation derives from data on LV thrombi associated with acute myocardial infarction, most frequently anterior ST elevation myocardial infarction (STEMI) [16, 17].…”

“…Possible mechanisms for thrombus formation in TTS are transient LV regional wall motion abnormalities resulting in the local activation of hemostasis, endocardial injury with regional exposure or release of thrombogenic substances and influence of catecholamines on nucleotide-induced platelet aggregation [10]. In the literature, most of the thrombi have been described in patients with apical TTS; however, in contrast to the assumption of Santoro et al [7, 9], midventricular TTS may equally be associated with thrombus formation, as seen in one of our patients [4, 6, 18, 19].…”

“…Several risk factors for LV thrombus formation have been described: apical TTS, significantly elevated levels of C-reactive protein and troponine, thrombocytosis, persisting ST segment elevation and right-ventricular involvement [3, 4, 7, 9]. It has been recommended to treat patients with TTS-related LV thrombi with anticoagulation for up to 3 months until LV function has completely normalized [7, 10, 11]. However, embolic events in patients with TTS-related thrombi despite therapeutic anticoagulation have been reported in the literature (Table 2) [2, 12-15].…”

Percutaneous Catheter Thrombus Aspiration of Right Renal Infarction Caused by Left Ventricular Thrombi due to Takotsubo Cardiomyopathy

“…In a previous report, anticoagulation therapy mainly with heparin or warfarin was used for LV thrombus. 4) If a thrombus appears with LV aneurysm after myocardial infarction, surgical thrombectomy with LV-plasty might be considered. There are only a few TC cases that underwent LV-plasty or thrombectomy in previous reports.…”

Giant Left Ventricular Thrombus in a Patient with Acute Ischemic Stroke: A Case Report and Minireview

“…The rare incidence of left ventricular thrombus has been reported in other diseases, including takotsubo cardiomyopathy [2], heparin-induced thrombocytopenia [3], Behçet disease [4], and disseminated intravascular coagulation [5]. There are limited data as to the exact frequency of LV thrombus in patients with ischemic stroke, but it has been reported to be about 2.4% in symptomatic patients by transesophageal echocardiography [6].…”