Takotsubo Cardiomyopathy With a Rapidly Resolved Left Ventricular Thrombus

Abstract

This article presents the case of a 53-year-old man who presented with acute right superficial femoral and popliteal arterial thrombosis for which he underwent an emergent uncomplicated thrombectomy. He denied preceding cardiovascular or neurologic symptomatology and had no history of coronary or peripheral arterial disease, trauma, hypercoagulability, or malignancy. However, he reported having several days of intense emotional stress prior to presentation. His cardiac exam was normal, his electrocardiogram showed normal sinus rhythm and nonspecific ST-T wave abnormalities, and his troponin levels were normal. Transthoracic echocardiography (TTE) revealed a large (2.4 × 2 cm) apical left ventricle (LV) thrombus, LV apical akinesis, and LV ejection fraction of 40% to 45%. Coronary angiography revealed only luminal irregularities. A repeat TTE performed 3 days after initiating unfractionated heparin revealed complete resolution of the LV thrombus. The patient had an uneventful clinical course and was discharged home in stable condition on oral anticoagulants. The lower incidence of LV thrombus in takotsubo cardiomyopathy (TC) of 1.3% in comparison to 4% to 8% in acute myocardial infarction due to coronary artery disease in the current era of early reperfusion may be explained by the lower extent of ischemic myocardial necrosis associated with TC. This case suggests that the lower extent of myocardial necrosis in TC may also lead to faster resolution of LV thrombus. Therefore, earlier follow-up with TTE (within 2 weeks) and shorter duration of anticoagulation (<3 months) may be considered in patients with TC complicated by LV thrombus formation with or without systemic embolism.

Takotsubo cardiomyopathy in a man with no trigger and multiple cardioembolic complications—A rare constellation

“…30 Patients with a more severe index presentation had higher risk of recurrence, whereas those prescribed ACE inhibitors at discharge had a lower risk. 23 Complete thrombus resolution is exceedingly rare within 7 days, as in our patient. 28,31 There is only one reported TC case complicated by a large apical LV thrombus which resolved within 3 days.…”

“…11 Contrary to previous notions, only 1/3rd of cases have emotional triggers. 3,[23][24][25] Cardioembolic events have been seen in about 1% of patients 23,26 and TC complicated by LV thrombus has a 92% female predominance; only one case has been reported in the literature with a renal infarct. 12 Acute prognosis is also worse than initially believed, 13 with in-hospital rates of death and shock being similar to age-and sex-matched ACS patients.…”

“…3 Secondary TS had a worse outcomes in the InterTAK registry. 23 Increased platelet reactivity and aggregation, as well as endothelial and cardiomyocyte dysfunction-induced by excess epinephrine and norepinephrine levels-have been postulated to produce intracardiac thrombi. RV involvement occurs in 20%.…”

“…Persistence to 6 months in one study was shown to be correlated with higher levels of myocardial damage by enzyme elevation, worse wall-motion abnormalities, and poorer outcomes including heart failure. [23][24][25] Multimodality imaging with echocardiography, CCTA, and CMR was key to making the correct diagnosis. 39 Our patient had a unique constellation of several unusual features of this uncommon disease-male sex, no emotional or physical trigger, LV thrombus on presentation, and 3 sites of cardio-embolism (brain, kidney, and lower extremity).…”

“…3,[23][24][25] Cardioembolic events have been seen in about 1% of patients 23,26 and TC complicated by LV thrombus has a 92% female predominance; only one case has been reported in the literature with a renal infarct. 23 Increased platelet reactivity and aggregation, as well as endothelial and cardiomyocyte dysfunction-induced by excess epinephrine and norepinephrine levels-have been postulated to produce intracardiac thrombi. 27 Left ventricular function recovery is variable, 28 with a median time of 12 weeks.…”