Alternative presentation of tako-tsubo syndrome with spontaneous echo-contrast and "onion" shaped apical ballooning

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

INTRODUCTION

Takotsubo syndrome (TTS) may be complicated by left-ventricular (LV) thrombus formation in 1.3-5.3% of patients. Risk factors for thrombi comprise apical TTS, elevated levels of C-reactive protein and troponine, thrombocytosis, persisting ST segment elevation and right-ventricular involvement. Embolic risk appears high, and anticoagulation is recommended.

CASE PRESENTATION

We present 3 females, aged 60-82 years, with TTS-associated LV thrombi and cerebral embolism despite therapeutic anticoagulation. Two patients showed apical and 1 patient midventricular ballooning. In 2 patients LV thrombi had not been present at the first echocardiographic examination. LV thrombi were multiple and highly mobile in 2 patients; 1 patient had a single immobile thrombus associated with spontaneous echocardiographic contrast (SEC). In each case, 3 of the described risk factors for LV thrombus formation were identified. The embolic stroke occurred 41-120 h after TTS symptom onset and 21-93 h after the initiation of therapeutic anticoagulation. Two patients were discharged with a neurological deficit, and 1 of them eventually died as a consequence of the stroke. LV thrombectomy to prevent embolism, which has been reported in a small number of cases, had not been considered in our patients.

CONCLUSION

At present, the management of patients with TTS-related thrombi is still unclear, and further studies are urgently needed to assess the best methods for imaging and anticoagulation and to determine the role of thrombolysis and cardiac surgery. Until these studies are available, we suggest the following approach: patients with a TTS-related thrombus should be monitored by echocardiography while receiving anticoagulation. In case of highly mobile LV thrombi, the heart team may consider cardiac surgery to prevent systemic embolism. The role of SEC in TTS remains to be determined.

Biventricular thrombosis in biventricular stress(takotsubo)-cardiomyopathy

Endo-ventricular thrombosis represents a possible clinical complication of stress(takotsubo)-cardiomyopathy (SC). Depressed ventricular systolic ventricular function, localized left ventricular (LV) dyskinesis, but also an increased pro-thrombotic state induced by catecholamine surge may facilitate the occurrence of endovascular thrombosis in SC. SC, however, may also present as right ventricular (RV) dysfunction or even as biventricular ballooning. Ventricular thrombosis may therefore theoretically occur in either ventricles or both. We report the case of an 88-year old woman, with vascular dementia and depression, admitted for abdominal pain, diarrhea, and rectal bleeding. Unexpectedly, electrocardiogram showed induced QT-prolongation with diffuse negative T-waves, while echocardiogram severe LV dysfunction (ejection fraction 35%), but also RV dysfunction and biventricular thrombosis. The diagnosis was therefore biventricular SC complicated by biventricular thrombosis; LV recovered after 10 days. When SC presents with a biventricular involvement, a careful assessment of either ventricular cavities should be therefore recommended to exclude the presence of (bi)ventricular thrombosis. It remains unresolved whether biventricular SC may represent a condition at higher risk of ventricular thrombosis.

Fast ‘wandering’ Takotsubo syndrome: atypical mixed evolution from apical to mid-ventricular ballooning

We report the case of a 53-year-old woman admitted for typical chest pain and a diagnosis of Takotsubo syndrome (TTS). Initial echocardiographic presentation was characterized by apical and mid-ventricular akinesis and basal hyper-kinesis. Unexpectedly, later after admission, echocardiography showed recovered apical akinesis with an apparent ‘migration’ of systolic dysfunction to mid-ventricular segment and hyper-kinesis of apical and basal segments. One week after admission, left ventricular contractility completely recovered and cardiac magnetic resonance imaging did not show signs of subendocardial late-enhancement and myocardial edema. Cases of TTS may therefore occasionally rapidly ‘wander’ within left ventricular segments, raising doubts over the so far used classification of left ventricular patterns of ballooning in subjects with TTS (typical/atypical). Apparently, different patterns can rapidly evolve into each other. The absence of late-enhancement at cardiac magnetic resonance imaging could hypothetically identify rapidly ‘wandering’ cases.

Therapy of stress (takotsubo) cardiomyopathy: present shortcomings and future perspectives

Several therapeutic options are available for the treatment of the acute phase of stress cardiomyopathy, pharmacological (β-blockers, diuretics, anticoagulants, antiarrhythmics, noncatecholamine inotropics [levosimendan]), and nonpharmacological (intra-aortic balloon pumping, extracorporeal membrane oxygenation), according to the wide possible clinical presentation and course of the disease. However, there is a gap in evidence, and very few data come from randomized and adequately powered studies. Some evidence supports the use of β-blockers, in particular with a short half-life, in the case of left ventricular outflow tract obstruction, and angiotensin-converting enzyme inhibitors in secondary prevention. Future perspectives include the study of genetic basis of stress cardiomyopathy, role of miRNA and neurovegetative modulation. Randomized studies, however, are surely warranted.