Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: a systematic review

Thromboembolic Complications in Takotsubo Cardiomyopathy

Apical ballooning syndrome, commonly known as Takotsubo syndrome, is a distinct cardiomyopathy often resembling acute myocardial infarction in presentation. Takotsubo syndrome patients exhibit varied patterns of left ventricular wall motion abnormalities, most frequently apical dyskinesis with basal hyperkinesis, that are characteristically transient. Although emotional or physical stressors precipitate Takotsubo syndrome in most cases, a significant proportion presents without identifiable triggers, with a pronounced female predominance. Despite recovery of left ventricular function, Takotsubo syndrome may lead to serious complications akin to acute coronary syndromes. The pathophysiology remains incompletely understood, with catecholamine surge implicated in the genesis of myocardial injury, although direct causation remains debated. Diagnosis involves integrating clinical history, imaging modalities like echocardiography, and cardiac MRI. Psychiatric disorders, particularly anxiety and depression, are frequently associated with Takotsubo syndrome, suggesting a role of chronic stress in disease susceptibility. Management includes supportive care, with anticoagulation considered in cases of apical thrombus, alongside close monitoring for complications and recovery of left ventricular function. This article reviews the current understanding, challenges in diagnosis, and management strategies for Takotsubo syndrome.

Noninvasive Assessment in Takotsubo Syndrome: A Diagnostic Challenge

Takotsubo syndrome (TTS) is a clinical syndrome characterized by a transient left ventricular dysfunction whose diagnosis can be challenging due to its resemblance to acute myocardial infarction (AMI). Despite the growing recognition of TTS, acute complications and long-term mortality rates are comparable to those observed in AMI patients. In this context, a systematic diagnostic approach is imperative for an accurate patient assessment, with due consideration of the distinctive characteristics and optimal timing of each imaging modality. Coronary angiography with ventriculography may be reserved for cases presenting with ST-segment elevation, whereas in all other cases, the use of multimodality noninvasive imaging allows for a comprehensive evaluation of typical diagnostic features and detection of acute complications while also providing prognostic insights. The aim of this review is to evaluate the current research on non-invasive modalities and to propose a diagnostic algorithm that will facilitate the identification and management of TTS.

Clinical Phenotypes and Outcomes of Patients with Left Ventricular Thrombus: An Unsupervised Cluster Analysis

BACKGROUND

Left ventricular thrombus (LVT) can develop in a diverse group of patients with various underlying causes resulting in divergent natural histories and trajectories with treatment. Our aim was to utilise cluster analysis to identify unique clinical profiles among LVT patients and then compare their clinical characteristics, treatment strategies, and outcomes.

METHODS

We conducted a retrospective study involving 472 LVT patients whose data was extracted from a tertiary center's echocardiography database, from March 2011 to January 2021. We employed the TwoStep cluster analysis method, examining 19 variables.

RESULTS

Our analysis of the 472 LVT patients revealed two distinct patient clusters. Cluster 1, comprising 247 individuals (52.3%), was characterized by younger patients with a lower incidence of traditional cardiovascular risk factors and relatively fewer comorbidities, compared to Cluster 2. Most patients had LVT attributed to an underlying ischaemic condition, with a larger proportion in Cluster 1 being due to post-acute myocardial infarction (68.8%), and Cluster 2 due to ischaemic cardiomyopathy (57.8%). Notably, patients in Cluster 2 exhibited a reduced likelihood of LVT resolution (HR 0.58, 95% CI 0.44 - 0.77, p < 0.001) and a higher risk of all-cause mortality (HR 2.27, 95% CI 1.43 - 3.60, p = 0.001). These associations persisted even after adjusting for variables like anticoagulation treatment, the presence of left ventricular aneurysms, and specific LVT characteristics such as mobility, protrusion, and size.

CONCLUSIONS

Through TwoStep cluster analysis, we identified two distinct clinical phenotypes among LVT patients, each distinguished by unique baseline clinical attributes and varying prognoses.

Takotsubo Syndrome and Gender Differences: Exploring Pathophysiological Mechanisms and Clinical Differences for a Personalized Approach in Patient Management

Takotsubo syndrome (TTS), also known as the broken-heart syndrome, is a reversible condition typically observed in female patients presenting for acute coronary syndromes (ACS). Despite its increasing incidence, TTS often remains undiagnosed due to its overlap with ACS. The pathophysiology of TTS is complex and involves factors such as coronary vasospasm, microcirculatory dysfunction, increased catecholamine levels, and overactivity of the sympathetic nervous system. Diagnosing TTS requires a comprehensive approach, starting with clinical suspicion and progressing to both non-invasive and invasive multimodal tests guided by a specific diagnostic algorithm. Management of TTS should be personalized, considering potential complications, the presence or absence of coronary artery disease (CAD), diagnostic test results, and the patient's clinical course. The current data primarily derive from case series, retrospective analyses, prospective registries, and expert opinions. In recent years, there has been growing recognition of gender differences in the pathophysiology, presentation, and outcomes of TTS. This review provides an updated overview of gender disparities, highlighting the importance of tailored diagnostic and management strategies.

Takotsubo Cardiomyopathy Following Insular Stroke in the M2 Area of the Left Middle Cerebral Artery

Takotsubo cardiomyopathy (TCM) is characterized as left ventricular apical ballooning in the absence of coronary occlusion. The most common trigger for TCM is emotional stress, but more cases are being reported demonstrating the association of TCM with intracranial pathologies. The pathophysiology of TCM is poorly understood but may be related to a surge of catecholamines, multivessel myocardial spasms, or neurologically mediated myocardial stunning. This case study describes the development of TCM after an ischemic stroke and establishes a possible association between the region of stroke and the development of TCM. We present the case of a 75-year-old woman who suffered a stroke of the left insular part (M2) of the middle cerebral artery (MCA) and subsequently experienced cardiac arrest with pulseless electrical activity and echocardiogram findings concerning for TCM within 24 hours. TCM should be recognized as a potential risk in the initial hours following a cerebral ischemic stroke, particularly when the insular region is affected. Prompt diagnosis and proper management of post-stroke TCM are essential for every patient presenting with new-onset cardiac dysfunction in stroke centers.

Ventricular Tachycardia in Patients With Takotsubo Cardiomyopathy: Prevalence, Predictors, and Associated In-Hospital Adverse Events

Introduction  The purpose of this study was to determine the prevalence of ventricular tachycardia (VT) among patients admitted with takotsubo cardiomyopathy (TCM) as well as to analyze the predictors of VT and the predictors of mortality among patients admitted with TCM. Methods Data were obtained from the National Inpatient Sample (NIS) database from January 2016 to December 2019. Patients with a primary diagnosis of TCM were selected using ICD-10 code I51.81. Subsequently, the study population was divided into patients who developed VT vs. patients who did not develop this complication. We then used multivariate logistic regression to assess the predictors of VT in our patient cohort as well as the predictors of mortality among patients admitted with TCM. Results  Of 40114 patients with TCM, 1923 developed VT (4.8%) during their hospital stay. Predictors of VT include atrial fibrillation (AF) (adjusted odds ratio (aOR): 1.592; 95% confidence interval (CI): 0.00-1.424; p=0.001), congestive heart failure (aOR: 1.451; 95% CI: 1.307-1.610; p=0.001), coagulopathy (aOR: 1.436; 95% CI: 1.150-1.793; p=0.001), and patients who self-identify in the race category as Other (aOR: 1.427; 95% CI: 1.086-1.875; p=0.011). Female sex was found to be protective against VT (aOR: 0.587; 95% CI: 0.526-0.656; p=0.001). Predictors of mortality among patients admitted with TCM include, among other factors, age (aOR: 1.014; 95% CI: 1.011-1.018; p=0.001), Asian or Pacific Islander race (aOR: 1.533; 95% CI: 1.197-1.964; p=0.001), Black race (aOR: 1.242; 95% CI: 1.062-1.452; p=0.007), VT (aOR: 1.754; 95% CI: 1.505-2.045; p=0.001), and AF (aOR: 1.441; 95% CI: 1.301-1.597; p=0.001). Some comorbidities that were protective against mortality in TCM include tobacco use disorder (aOR: 0.558; 95% CI: 0.255-0.925; p=0.028) and obstructive sleep apnea (aOR: 0.803; 95% CI: 0.651-0.990; p=0.028). The female sex was found to be protective against mortality (aOR: 0.532; 95% CI: 0.480-0.590; p=0.001).  Conclusion  In a large cohort of women admitted with TCM, we found the prevalence of VT to be 4.8%. Predictors of VT included conditions such as AF and congestive heart failure. The female sex was found to be protective against VT and protective against mortality among patients admitted with TCM.

Takotsubo Syndrome and Coronary Artery Disease: Which Came First-The Chicken or the Egg?

Takotsubo syndrome (TTS) is a clinical condition characterized by temporary regional wall motion anomalies and dysfunction that extend beyond a single epicardial vascular distribution. Various pathophysiological mechanisms, including inflammation, microvascular dysfunction, direct catecholamine toxicity, metabolic changes, sympathetic overdrive-mediated multi-vessel epicardial spasms, and transitory ischemia may cause the observed reversible myocardial stunning. Despite the fact that TTS usually has an acute coronary syndrome-like pattern of presentation, the absence of culprit atherosclerotic coronary artery disease is often reported at coronary angiography. However, the idea that coronary artery disease (CAD) and TTS conditions are mutually exclusive has been cast into doubt by numerous recent studies suggesting that CAD may coexist in many TTS patients, with significant clinical and prognostic repercussions. Whether the relationship between CAD and TTS is a mere coincidence or a bidirectional cause-and-effect is still up for debate, and misdiagnosis of the two disorders could lead to improper patient treatment with unfavourable outcomes. Therefore, this review seeks to provide a profound understanding of the relationship between CAD and TTS by analyzing potential common underlying pathways, addressing challenges in differential diagnosis, and discussing medical and procedural techniques to treat these conditions appropriately.

Pharmacological Triggers of Takotsubo Cardiomyopathy: An Updated Review of Evidence and Recommendations

BACKGROUND

Previous publications in 2011, 2016, and 2022 have presented lists of drugs associated with takotsubo cardiomyopathy (TCM). This review aims to provide updated drug lists that have been reported as potential causes of TCM.

METHODS

Following the same methodology employed in previous reviews, a detailed investigation was carried out in the PubMed/Medline database from June 2022 to July 2023 to identify drug-induced TCM (DITC) case reports. Various search terms related to the drug-induced transient left ventricular ballooning syndrome, ampulla cardiomyopathy, apical ballooning syndrome, drug-induced broken heart syndrome, drug triggered takotsubo cardiomyopathy, takotsubo cardiomyopathy, and iatrogenic takotsubo cardiomyopathy were utilized. Filters for fulltext availability, case reports, human studies, and English language were applied. Articles reporting drugs associated with TCM development were included in the analysis.

RESULTS

Foremost 192 case reports were initially identified, with 75 drugs meeting the inclusion criteria after a thorough review. The latest revision identified seven drugs that might lead to TCM, with four drugs (57.14%) already reported in previous reviews and three drugs (42.86%) newly identified. Consequently, the updated drug list potentially triggering TCM in 2023 comprises a sum of 75 drugs.

CONCLUSION

The recent 75 drugs provided additional evidence linking to TCM development. The updated list predominantly includes drugs that induce sympathetic overstimulation, although some drugs on the list have unclear associations with sympathetic nervous system activation.

Takotsubo syndrome and stroke risk: A nationwide register-based study

AIMS

Previous small-scale studies have indicated a short-term stroke incidence of 1.0-1.3% following Takotsubo (syndrome). In this nationwide register-based study, we investigated the 90-day risk of ischemic stroke (IS) or transient ischemia attack (TIA) and mortality of patients with Takotsubo.

METHODS AND RESULTS

Patients with incident Takotsubo between January 1st 2009 to September 30th 2018 were identified from Danish nationwide registries. Takotsubo patients were age- and sex-matched with background-, atrial fibrillation/flutter- (AF) and myocardial infarction (MI) cohorts. Cumulative incidences and Cox proportional-hazard regression models were used to analyze the following outcomes: 1) composite of IS/TIA and 2) all-cause mortality. A total of 890 patients with Takotsubo were followed for 90 days. The cumulative 90-day incidence of IS/TIA in the Takotsubo-, background-, AF- and MI cohort, was 2.1% (n = 19), 0.1% (n = 4), 1.1% (n = 47) and 1.5% (n = 66), respectively. The cumulative 90-day mortality in the Takotsubo-, background-, AF- and MI cohort was 5.1% (n = 45), 0.3% (n = 13), 1.7% (n = 75) and 5.6% (n = 230), respectively. The adjusted hazard ratio (HR) for 90-day IS/TIA was when compared to the background-, AF- and MI cohort, 26.43 (95% CI: 8.82-79.24), 1.91 (95% CI: 1.09-3.35) and 2.06 (95% CI: 1.12-3.79), respectively. The adjusted HR for 90-day mortality was when compared to the background-, AF- and MI cohort, 14.19 (95% CI: 7.43-27.09), 0.73 (95% CI: 0.52-1.02) and 1.96 (95% CI: 1.25-3.07), respectively.

CONCLUSION

Patients with Takotsubo had an increased 90-day hazard for IS/TIA when compared to age- and sex-matched background-, AF- and MI cohorts.

Transmitral Thrombectomy via Minithoracotomy in a Patient with Takotsubo Cardiomyopathy

Left ventricular thrombus is a complication of myocardial infarction, ventricular aneurysm, myocarditis, and cardiomyopathies, such as Takotsubo syndrome. We report the case of a 74-year-old woman who was diagnosed as left ventricular thrombus resulting from transient Takotsubo syndrome. The thrombus was completely removed using video-assisted thoracoscopy through right minithoracotomy. This approach is less invasive and can provide better visualization, thereby avoiding left ventriculotomy.

Takotsubo syndrome: A current review of presentation, diagnosis, and management

Takotsubo syndrome is a syndrome of acute heart failure due to left ventricular systolic dysfunction that is associated with increased cardiovascular morbidity and mortality. It occurs in both sexes and at all ages, but predominates in post-menopausal women for reasons that are unclear. In a patient who presents with cardiac symptoms, electrocardiographic changes, and/or biomarker elevation indicating myocardial stress (i.e. troponin elevation), this condition should be considered in the differential diagnosis. Cardiac imaging is critical for a timely diagnosis of this condition and has management implications. This syndrome can occur with or without underlying coronary artery disease, and while there are various characteristic myocardial patterns described on imaging, the most common one is left ventricular dysfunction due to apical stunning with basal hyperkinesis. In the acute phase, Takotsubo syndrome can lead to life-threatening sequelae, including cardiogenic shock, pulmonary edema, thromboembolism, and arrhythmias. Multiple pathophysiologic mechanisms are implicated, including an acute increase in left ventricular afterload in the setting of sympathetic activation with a catecholamine storm, multi-vessel coronary vasospasm, coronary endothelial microvascular dysfunction, and inflammation. In this review, we discuss the current knowledge surrounding presentation, diagnosis, and treatment of this under-diagnosed condition.

The impact of ST-segment elevation on the prognosis of patients with Takotsubo cardiomyopathy

INTRODUCTION

Takotsubo cardiomyopathy (TC) has a variety of electrocardiographic expressions such as ST-segment elevation (STE), T-wave inversion, QTc-prolongation, left bundle branch block, presence of anterior Q waves and rarely ST-segment depression. In contrast to acute myocardial infarction, the impact of STE on the initial electrocardiogram (EKG), on TC outcomes, remains largely unknown.

OBJECTIVE

To evaluate the significance of STE on the index EKG of patients with takotsubo cardiomyopathy (TC) in terms of prognosis.

METHODS

We examined retrospectively the data of 436 patients diagnosed with TC who were admitted to the Minneapolis Heart Institute between August 2001 and November 2019.

RESULTS

Of 436 patients, 145 (33%) presented with STE on the index EKG. Typical apical ballooning pattern was encountered more frequently in the STE group (66% vs 51%; p = 0.005), on the contrary to the mid-ventricular ballooning which was more common in the non-STE group (31% vs 45%; p = 0.005) while initial left ventricular ejection fraction was similar between the two groups (31% ± 9 vs 33% ± 11; p = 0.163). The composite endpoint of TC-related complications, defined as left ventricular outflow tract obstruction (LVOTO), left ventricular (LV) thrombus, hemodynamic instability requiring mechanical or intravenous vasopressor support, cardiac arrest or in-hospital death, was higher for the STE group (37% vs 24%; p = 0.006). Left ventricular outflow obstruction (LVOTO) was more frequent in patients with STE (13% vs 3%; p < 0.001) while there was a trend toward higher rates of LV thrombus formation in the same group (5% vs 1%; p = 0.057). On multivariable analysis, STE remained an independent predictor of TC-related complications. In-hospital mortality (2.8% vs 3.4%; p = 1.000) and five-year mortality were similar between the two groups (23% vs 20%; p = 0.612).

CONCLUSION

Patients with TC presenting with STE on the initial EKG, were more likely to develop disease related complications, thus, careful in-hospital monitoring including imaging evaluation for LVOTO and LV thrombus may be warranted for these patients. Nevertheless, both groups had similar in-hospital and five-year mortality.

Arrhythmias and Their Electrophysiological Mechanisms in Takotsubo Syndrome: A Narrative Review

BACKGROUND

Takotsubo syndrome (TTS), an acute and usually reversible condition, is associated with both tachy- and bradyarrhythmias. Such arrhythmias can be life-threatening, e.g. ventricular tachycardia and fibrillation, and associated with cardiac arrest. Others, such as atrioventricular block, persist and require long-term device therapy. In this narrative review, we aim to provide a summary of the current literature on arrhythmias in TTS and their clinical sequelae.

METHODS

PubMed and Medline databases were searched with various permutations of TTS, arrhythmias and beta-adrenoceptors. After application of exclusion criteria and review, 84 articles were included.

RESULTS

Although there are no specific electrocardiograph (ECG) findings in TTS to differentiate it from ST-elevation myocardial infarction, suggestive patterns include small QRS amplitude, ST segment elevation without reciprocal ST depression and prolonged QT interval. Atrial tachyarrhythmias (incidence of 5-15%) are associated with a more unwell patient cohort. Ventricular arrhythmias (incidence 4-14%) are often associated with prolonged QT interval and are a cause of sudden death in TTS. Bradyarrhythmias are less common (incidence 1.3-2.5%), but have been reported with TTS, and usually persist beyond the acute phase.

CONCLUSIONS

Takotsubo syndrome, though considered primarily a disease of the myocardium, carries multiple arrhythmic manifestations that affect short- and long-term prognosis. The management of such arrhythmias represents a constantly evolving area of research.

Takotsubo Syndrome in New Zealand: Current Knowledge and Future Challenges

Takotsubo syndrome (TS), also known as apical ballooning syndrome is a transient stress-related cardiomyopathy characterised by acute but reversible left ventricular dysfunction. The condition tends to occur in postmenopausal women after a stressful event. At presentation TS typically mimics acute myocardial infarction (MI) and the incidence of TS has been increasing worldwide. This is likely a consequence of an improved awareness of the existence of this syndrome and easier access to early echocardiography and coronary angiography. However, its aetiology remains poorly understood and it is probably still underdiagnosed. Similar to other countries. TS is being increasingly recognised in New Zealand. In this review, we discuss the demographics, clinical features and outcomes of patients with TS in New Zealand. Doing so informs us not only of the pattern of disease in New Zealand but it also provides insights into the condition itself. This article is protected by copyright. All rights reserved.

Takotsubo Syndrome: A Review of Presentation, Diagnosis and Management

Takotsubo Syndrome (TTS) is a condition of transient left ventricular dysfunction that is typically triggered by emotional or physical stress. Since first described in Japan in 1990, it has increasingly been recognised in clinical practice, accounting for up to 2% of Acute Coronary Syndrome (ACS) presentations. In fact, the clinical presentation can be indistinguishable from a myocardial infarction. Although current evidence suggests a catecholamine induced myocardial stunning, the pathophysiological mechanisms remain unknown. Interestingly, it is more common in woman, particularly those who are post-menopausal. This review aims to summarise the current research and provide an overview of the diagnostic strategies and treatment options.

Takotsubo Syndrome in Intensive Cardiac Care Unit: Challenges in Diagnosis and Management

Takotsubo syndrome (TTS) is an acute reversible form of myocardial dysfunction that is often associated with serious adverse in-hospital complications, including acute heart failure, cardiogenic shock and life-threatening arrythmias. In the absence of randomized clinical trials, its management in the acute phase is based on empirical supportive pharmacological and non-pharmacological measures.In this review article, we aimed at providing an overview of the acute clinical manifestations of patients presenting with TTS, highlighting the predictors of a worse short-term outcome, along with the challenges in therapeutic management of TTS-related complications in the acute care setting.

Takotsubo Cardiomyopathy: Current Treatment

Management of takotsubo syndrome (TTS) is currently empirical and supportive, via extrapolation of therapeutic principles worked out for other cardiovascular pathologies. Although it has been emphasized that such non-specific therapies for TTS are consequent to its still elusive pathophysiology, one wonders whether it does not necessarily follow that the absence of knowledge of TTS' pathophysiological underpinnings should prevent us for searching, designing, or even finding, therapies efficacious for its management. Additionally, it is conceivable that therapy for TTS may be in response to pathophysiological/pathoanatomic/pathohistological consequences (e.g., "myocardial stunning/reperfusion injury"), common to both TTS and coronary artery disease, or other cardiovascular disorders). The present review outlines the whole range of management principles of TTS during its acute phase and at follow-up, including considerations pertaining to the recurrence of TTS, and commences with the idea that occasionally management of TTS should consist of mere observation along the "first do no harm" principle, while self-healing is under way. Finally, some new therapeutic hypotheses (i.e., large doses of insulin infusions in association with the employment of intravenous short- and ultrashort-acting β-blockers) are being entertained, based on previous extensive animal work and limited application in patients with neurogenic cardiomyopathy and TTS.

Successful Conservative Treatment of Cardiac Rupture Associated with Takotsubo Syndrome

We herein report a 75-year-old woman who was diagnosed with Takotsubo syndrome (TTS) complicated by left ventricular outflow tract obstruction on admission. Treatment with beta-blocker and anticoagulant was started; however, her hemoglobin level decreased gradually, and computed tomography performed one week later revealed hemopericardium. Oozing-type cardiac rupture was suspected; therefore, we discontinued heparin treatment. Finally, she recovered uneventfully without cardiac surgery. It is noteworthy that cardiac rupture may occur with TTS, especially in patients treated with prophylactic anticoagulation therapy for apical thrombus. Furthermore, conservative, careful observation is an alternative approach in patients with oozing-type cardiac rupture associated with TTS.

Thromboembolic complications following intravenous immunoglobulin therapy in immune-mediated neurological disorders

BACKGROUND

Minor adverse events of intravenous immunoglobulin (IVIg) include flu-like symptoms, eczematous skin reaction, electrolyte disturbance, and transient leukopenia. On rare occasions, serious complications such as aseptic meningitis, arrhythmia, decrease in blood pressure, and thromboembolic complications (TEC) have been described. The current study aimed to understand the frequency and clinical features of TEC related to IVIg administration in patients with immune-mediated neurological disorders.

METHODS

We conducted a retrospective chart review of hospitalized patients with immune-mediated neuromuscular or neuroimmunological disorders treated with IVIg from January 2018 to March 2020 in a single tertiary hospital.

RESULTS

During the study period, 61 patients were treated with a total of 364 IVIg infusions over 84 treatment courses. Among them, we identified 3 TEC cases that occurred during or after the completion of IVIg therapy: two patients with myasthenia gravis (F/60 and F/80) and one patient with Guillain-Barré syndrome (F/79) had undergone arterial TEC (two for ischemic stroke and one for pulmonary thromboembolism). The rates of TEC per patient, per treatment course, and per infusion were 4.91% (3/61), 3.57% (3/84), and 0.82% (3/364), respectively.

CONCLUSION

The risk of developing TEC upon receiving IVIg infusions is generally low in patients with immune-mediated neurological disorders; however, IVIg-related TEC should be cautiously monitored for in critically ill elderly patients with vascular risk factors, especially those suffering from myasthenic crisis.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Update of takotsubo syndrome in the era of COVID-19

Takotsubo cardiomyopathy or takotsubo syndrome (TTS) has become a well-known disease not only in Japan but also in the rest of the world. Early reports suggested that TTS is a self-limiting disease with better prognosis than acute coronary syndrome. However, recent data showed that TTS is not a benign disease as compared with acute coronary syndrome. In addition to the apical ballooning, several other types of wall motion abnormalities have been classified as variants of TTS. In particular, right ventricular involvement, or biventricular TTS, is not uncommon and is associated with poor in-hospital as well as long-term outcomes. With respect to the pathophysiology, modulation (desensitization) of the beta-adrenergic receptor is suspected as a possible mechanism for transiently depressed myocardial contraction. Although specific treatments to improve prognosis of TTS are still uncertain, observational data suggest favorable impact of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers. Finally, in the era of COVID-19, we should pay attention to a variety of cardiovascular conditions related to COVID-19. TTS is one of these conditions that can be triggered by both emotional and physical impact of the COVID-19 pandemic.

Multimodality imaging in takotsubo syndrome: a joint consensus document of the European Association of Cardiovascular Imaging (EACVI) and the Japanese Society of Echocardiography (JSE)

Takotsubo syndrome (TTS) is a complex and still poorly recognized heart disease with a wide spectrum of possible clinical presentations. Despite its reversibility, it is associated with serious adverse in-hospital events and high complication rates during follow-up. Multimodality imaging is helpful for establishing the diagnosis, guiding therapy, and stratifying prognosis of TTS patients in both the acute and post-acute phase. Echocardiography plays a key role, particularly in the acute care setting, allowing for the assessment of left ventricular (LV) systolic and diastolic function and the identification of the typical apical-midventricular ballooning pattern, as well as the circumferential pattern of wall motion abnormalities. It is also useful in the early detection of complications (i.e. LV outflow tract obstruction, mitral regurgitation, right ventricular involvement, LV thrombi, and pericardial effusion) and monitoring of systolic function recovery. Left ventriculography allows the evaluation of LV function and morphology, identifying the typical TTS patterns when echocardiography is not available or wall motion abnormalities cannot be properly assessed with ultrasound. Cardiac magnetic resonance provides a more comprehensive depiction of cardiac morphology and function and tissue characterization and offers additional value to other imaging modalities for differential diagnosis (myocardial infarction and myocarditis). Coronary computed tomography angiography has a substantial role in the diagnostic workup of patients with acute chest pain and a doubtful TTS diagnosis to rule out other medical conditions. It can be considered as a non-invasive appropriate alternative to coronary angiography in several clinical scenarios. Although the role of nuclear imaging in TTS has not yet been well established, the combination of perfusion and metabolic imaging may provide useful information on myocardial function in both the acute and post-acute phase.

Giant Left Ventricular Thrombus Formation in the Setting of Severe Aortic Stenosis and Heavy Cigarette Smoking

The harmful effects of cigarette smoking on the human body have been well documented. However, whether tobacco use is an independent risk factor of valvular heart disease remains debatable. Cigarette smoking has been associated with an inflammatory state and increased levels of tumor necrosis factor alpha, which in turn activates protein kinases involved in ventricular remodeling. Subsequent ventricular dysfunction predisposes to the formation of mural thrombi which may lead to further worsening of hemodynamics. We present a case of severe aortic stenosis and giant left ventricular thrombus formation associated with chronic cigarette smoking.

Intraventricular Thrombus Formation and Embolism in Takotsubo Syndrome

Objective:

Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction, which can contribute to intraventricular thrombus and embolism. Still, prevalence and clinical impact of thrombus formation and embolic events on outcome of TTS patients remain unclear. This study aimed to investigate clinical features and outcomes of patients with and without intraventricular thrombus or embolism. Additionally, factors associated with thrombus formation or embolism, as well as predictors for mortality, were identified.

Approach and Results:

TTS patients enrolled in the International Takotsubo Registry at 28 centers in Australia, Europe, and the United States were dichotomized according to the occurrence/absence of intraventricular thrombus or embolism. Patients with intraventricular thrombus or embolism were defined as the ThrombEmb group. Of 1676 TTS patients, 56 (3.3%) patients developed intraventricular thrombus and/or embolism following TTS diagnosis (median time interval, 2.0 days [range, 0–38 days]). Patients in the ThrombEmb group had a different clinical profile including lower left ventricular ejection fraction, higher prevalence of the apical type, elevated levels of troponin and inflammatory markers, and higher prevalence of vascular disease. In a Firth bias-reduced penalized-likelihood logistic regression model apical type, left ventricular ejection fraction ≤30%, previous vascular disease, and a white blood cell count on admission >10×10 3 cells/μL emerged as independent predictors for thrombus formation or embolism.

Conclusions:

Intraventricular thrombus or embolism occur in 3.3% of patients in the acute phase of TTS. A simple risk score including clinical parameters associated with intraventricular thrombus formation or embolism identifies patients at increased risk.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01947621.

Improved Outcome of Cardiogenic Shock Triggered by Takotsubo Syndrome Compared With Myocardial Infarction

BACKGROUND

Cardiogenic shock (CS) is a severe complication of myocardial infarction (MI) or of takotsubo syndrome (TTS). For both diseases, CS is related to a worse long-term outcome. The outcome of CS has not been studied in a direct comparison of patients with MI and patients with TTS.

METHODS

Mortality and cardiovascular complications were compared in patients presenting with CS based on MI or TTS between 2003 and 2017 during a follow-up of 5 years. A total of 138 patients with TTS and 532 patients with MI were included. Of these, 66 patients with MI and 25 patients with TTS developed CS (12% vs 18%, P = 0.08).

RESULTS

Patients with MI and CS had more often malignant arrhythmias (74% vs 28%, P < 0.01), and need for resuscitation (80% vs 24%, P < 0.01) or death (71% vs 24%, P < 0.01) than patients with TTS and CS during the first 30 days. Although the overall rate of death remained higher in MI than in TTS (75.8% vs 52%, log rank, P < 0.01), deaths occurred in TTS constantly throughout the follow-up time, but not in MI. The incidence of heart failure increased in MI but not in TTS (31.8% vs 4%, P < 0.01) during follow-up.

CONCLUSIONS

Patients with MI and CS have a worse prognosis than patients with TTS and CS. This is driven by cardiovascular events or death during the first 30 days after the index event. However, patients with TTS and CS show high mortality as well, especially during long-term follow-up.

[Endovascular closure of a ventricular septal defect from Takotsubo Syndrome]

Takotsubo Syndrome is a transient condition characterized by left ventricular systolic dysfunction. Although the prognosis is excellent in most cases, rare cases of serious complications can occur. We present a case of a 81-year - old woman with Takotsubo Syndrome complicated by ventricular septal rupture that was successfully closed with an occluder Occlutech with good immediate and long - term outcomes.

Intraventricular thrombus and severe mitral regurgitation in the acute phase of takotsubo cardiomyopathy: two case reports

Background

Takotsubo cardiomyopathy is characterized by chest symptoms, electrocardiographic changes, and new regional wall motion abnormality in the apical segment of the left ventricle in the absence of obstructive coronary artery disease. Particularly, apical ballooning is broadly recognized as the classic form of takotsubo cardiomyopathy. Although the prognosis of most patients with takotsubo cardiomyopathy is generally favorable, complications associated with the morphological features of transient apical ballooning are not uncommon.

Case presentation

We describe two cases of transient complications in postmenopausal patients with takotsubo cardiomyopathy. Intraventricular thrombus was observed in Asian patient 1, and severe mitral regurgitation was observed in Asian patient 2. These complications were confirmed by transthoracic echocardiography immediately after typical takotsubo cardiomyopathy with apical ballooning was diagnosed. Anticoagulant therapy with heparin and warfarin was continued for 1 week in patient 1. After the therapy, complete resolution of the apical thrombus and recovery of systolic function of the left ventricle was observed by follow-up transthoracic echocardiography. In patient 2, transthoracic echocardiography indicated significant mitral regurgitation, which was caused by left ventricular tethering of the anterior mitral leaflet rather than left ventricular outflow tract obstruction or systolic anterior motion. Because the hemodynamic stability in patient 2 had been preserved, she was managed with conservative treatment. After approximately 1 month, follow-up transthoracic echocardiography revealed that mitral regurgitation had almost disappeared with complete resolution of left ventricular wall motion abnormalities.

Conclusions

The presented cases indicated that important complications, such as intraventricular thrombus and severe mitral regurgitation, are associated with takotsubo cardiomyopathy in the acute phase. Because these complications are risk factors for developing a thromboembolic event or heart failure and/or pulmonary edema, timely and accurate identification of these complications is critical to achieving optimal clinical outcomes in patients with takotsubo cardiomyopathy.

Short- and Long-Term Incidence of Thromboembolic Events in Takotsubo Syndrome as Compared With Acute Coronary Syndrome

Thromboembolic events are a common complication in Takotsubo syndrome (TTS). However, their long-term incidence compared with acute coronary syndrome (ACS) is lacking. In-hospital and long-term incidence of thromboembolic events of 138 consecutive patients with TTS were compared with 138 sex- and age-matched patients with ACS. Predictors of events were analyzed. The incidence of thromboembolic events in TTS was 2-fold higher than ACS (21% vs 9%; P < .01) over a mean follow-up of 5 years. Although the left ventricular ejection fraction (LVEF) at event was significantly lower in TTS compared with ACS (38% [9%] vs 54% [11%]; P < .01), the follow-up LVEF was comparable. Patients with TTS suffering from thromboembolic events were more often treated with anticoagulation compared with ACS (44.8% vs 8.3%, P = .03). However, more patients presenting with ACS (100% vs 48.3%; P < .01) were discharged on aspirin. Only elevated C-reactive protein was a predictor of thromboembolic events using multivariate analysis (hazard ratio 1.1, 95% confidence interval, 1.0-1.2; P < .01). In conclusion, the risk of thromboembolic events in TTS was significantly higher than the risk of thromboembolic events in ACS over a mean follow-up of 5 years.

Left ventricular wall motion abnormality is associated with cryptogenic stroke

BACKGROUND

Left ventricular wall motion abnormality (LVWMA) unrelated to known cardiac risk factors is an uncertain risk for stroke.

AIMS

We evaluated whether LVWMA was associated with cryptogenic stroke.

METHODS

This retrospective, observational study included 4316 acute ischemic stroke patients, and the association between cryptogenic stroke and LVWMA was examined in comparison with other stroke subtypes.

RESULTS

The prevalence of LVWMA was 10.0% in the study population. In a fully adjusted, binary logistic regression, LVWMA was independently associated with cryptogenic stroke compared with stroke from large artery atherosclerosis (odds ratio = 1.627, 95% confidence interval = 1.129-2.345), small vessel occlusion (odds ratio = 1.948, 95% confidence interval = 1.261-3.010), or other causes (odds ratio = 4.950, 95% confidence interval = 1.145-21.412). Meanwhile, the association of LVWMA with cryptogenic stroke was similar to the associations of LVWMA with cardioembolic stroke (odds ratio = 0.758, 95% confidence interval = 0.525-1.094) and stroke with two or more causes (odds ratio = 0.992, 95% confidence interval = 0.609-1.615). In multinomial regression, LVWMA had the strongest association with cardioembolic stroke, followed by cryptogenic stroke and stroke from two or more causes. The strength of the associations with LVWMA then decreased sequentially in patients with large artery atherosclerosis, small vessel occlusion, and other causes.

CONCLUSIONS

The association of LVWMA with cryptogenic stroke was comparable to that of LVWMA with cardioembolic stroke but stronger than that of LVWMA with non-cardioembolic stroke. LVWMA unrelated to known cardiac risk factors could be considered an independent risk factor for cryptogenic stroke.

Sex-Specific Physiology and Cardiovascular Disease

Sex differences in cardiovascular diseases can be classified as those which are specific to one sex and those that differ in incidence, prevalence, etiology, symptomatology, response to treatment, morbidity, and mortality in one sex compared to the other. All sex differences in cardiovascular conditions have their basis in the combined expression of genetic and hormonal differences between women and men. This chapter addresses how understanding basic mechanisms of hormone responses, imaging diagnostics, and integration of genomics and proteomics has advanced diagnosis and improved outcomes for cardiovascular conditions, apart from those related to pregnancy that are more prevalent in women. These conditions include obstructive coronary artery disease, coronary microvascular dysfunction, spontaneous coronary artery dissection, diseases of the cardiac muscle including heart failure and takotsubo cardiomyopathy, and conditions related to neurovascular dysregulation including hot flashes and night sweats associated with menopause and effects of exogenous hormones on vascular function. Improvement in technologies allowing for noninvasive assessment of neuronally mediated vascular reactivity will further improve our understanding of the basic etiology of the neurovascular disorders. Consideration of sex, hormonal status, and pregnancy history in diagnosis and treatment protocols will improve prevention and outcomes of cardiovascular disease in women as they age.

Impact of ST-segment elevation on the outcome of Takotsubo syndrome

Background

Recent studies have highlighted that Takotsubo syndrome (TTS), mimicking acute coronary syndrome (ACS), is associated with poor clinical outcome. TTS is associated with different repolarization disorders including ST-segment elevation. ST elevation myocardial infarction (STEMI) in ACS is associated with declined prognosis. However, the clinical and prognostic impact of ST-segment elevation on TTS remains lacking.

Aim

The aim of this study was to determine the short- and long-term prognostic impact of ST-segment elevation on TTS patients as compared with STEMI patients.

Patients and methods

Our institutional database constituted a consecutive cohort of 138 TTS patients and 138 ACS patients matched for age and sex. TTS patients (n=41) with ST-segment elevation were compared with ACS patients with ST-segment elevation (n=64).

Results

Chest pain was significantly more documented in STEMI patients as compared with TTS patients (48.8% vs 78.1%; P<0.01). Cardiovascular risk factors such as diabetes mellitus (12.2% vs 29.7%; P=0.02) were significantly more presented in STEMI patients. Although the initial left ventricular ejection fraction (LVEF) was more declined in TTS patients (39%±9% vs 45%±16%; P<0.01), the LVEF was more declined in STEMI patients at follow-up (54%±10% vs 45%±16%; P=0.04). Inhospital complications such as respiratory failure were significantly more presented in TTS patients (68.3% vs 20.3%; P<0.01). The short-term as well as the long-term morality was similar in both groups. In univariate analysis, male sex, ejection fraction (EF) <35%, glomerular filtration rate (GFR) <60 mL/min, cardiogenic shock, inotropic drugs, and history of cancer were predictors of 5-year mortality.

Conclusion

Rates of the long-term mortality in TTS patients with ST elevations are comparable with STEMI patients.

Thrombo-embolic complications in takotsubo syndrome: Review and demonstration of an illustrative case

Thrombo-embolism is one of the serious complications of takotsubo syndrome (TS) in addition to heart failure, pulmonary edema, cardiogenic shock, cardiac arrest, life-threatening arrhythmias, left ventricular outlet tract obstruction, mitral regurgitation, cardiac rupture, and death. The most common cardio-embolic events in TS are cerebral, renal, and peripheral embolism. Approximately, one-third of patients with left ventricular thrombus (LVT) in TS develop embolic complications. Cardio-embolism in TS may occur with or without the presence of detectable LVT. In the present report, the thrombo-embolic complications in TS with the emphasis on the association of TS to both acute coronary syndrome (ACS) including coronary embolism and ischemic stroke including cerebral embolism are reviewed. This serious complication is elucidated by demonstration of the case of a 67-year-woman with mid-apical TS complicated by LVT, left anterior descending artery (LAD) and left middle cerebral artery (segment M2) thrombo-embolic occlusions. The cerebral artery thrombotic occlusion was treated successfully with endovascular thrombectomy with complete resolution of the neurological deficits. There was spontaneous recanalization of the apical LAD occlusion verified by cardiac computed tomography angiography.

Anticoagulation and stress-induced cardiomyopathy

Stress-induced cardiomyopathy (SCM), is a reversible cardiomyopathy characterized by transient systolic dysfunction following an acute physiologic stress. Thromboembolism occurs at a high frequency in patients with intracardiac thrombus secondary to SCM, with one systematic review reporting a rate of 33.3%. The risk of thrombus formation following SCM has been associated with left-ventricular (LV) contraction abnormalities, catecholaminergic surge, and other associated comorbidities. However, established guidelines for screening and management of intracardiac thrombus in the setting of SCM do not exist at present due to a lack of sufficient clinical trial data. The purpose of this article is to discuss the pathophysiological theory and previously documented evidence from cases of LV thrombus secondary to SCM, and to present our recommendations for management of intracardiac thrombus secondary to SCM.

Takotsubo Cardiomyopathy-Induced Cardiac Free Wall Rupture: A Case Report and Review of Literature

Takotsubo cardiomyopathy (TCM) is an acquired form of cardiomyopathy that is commonly seen among post-menopausal women. It is characterized by left ventricular apical ballooning, electrocardiographic changes and mild elevation of cardiac enzymes in the absence of significant coronary artery stenosis. TCM usually has benign course. However, on rare instance, it can result in life-threatening and fatal complications including acute cardiogenic shock, ventricular arrhythmias and ventricular wall rupture. We herein report a case of a 77-year-old female who developed TCM complicated with massive pericardial effusion and cardiac arrest. The patient died and autopsy revealed normal coronaries with a slit-like rupture on the antero-apical surface of the heart extending into the papillary muscle. The clinical course, labs and angiographic findings preceding the cardiac rupture will be outlined. A thorough literature review including review of 14 previously reported case reports of TCM complicated with cardiac rupture will be included.

Acute arterial occlusion due to left ventricular thrombus of Takotsubo cardiomyopathy in a young adult: a case report

Background

Thromboembolism is a rare complication of Takotsubo cardiomyopathy. Importantly, an acute arterial occlusion needs rapid diagnosis and urgent treatment to help save the patient’s life. Here, we report a case of arterial occlusion due to ventricular thrombus of Takotsubo cardiomyopathy.

Case presentation

A woman in her 30s, without previous medical history, felt sudden strong pain on her right leg and was diagnosed with right femoral arterial occlusion. An emergency operation was subsequently performed to take out thrombus. The patient’s oxygenation deteriorated to 93% of hemoglobin saturation just after extubation and exacerbated in the intensive care unit. Transthoracic echocardiography revealed Takotsubo cardiomyopathy-like left ventricular wall motion abnormalities and left ventricular thrombus. Heparin treatment was immediately started. After 10 days, the thrombus disappeared and the left ventricular wall motion improved and she was discharged from the hospital.

Conclusions

The patient’s acute arterial occlusion in this case report was mainly caused by thrombus of cardiac origin. We suggest to routinely check echocardiography reports before surgery and perform anesthetic management carefully to better control the patient’s blood pressure and heart rhythm.

A Case of Left Ventricular Thrombus with Superior Mesenteric Vein Thrombosis Due to Atopic Dermatitis

A 55-year-old man was presented to the emergency room because of abdominal pain for 4 days. He had a history of atopic dermatitis. Left ventricular (LV) asynergy and thrombus was detected on echocardiography, and superior mesenteric vein thrombosis was detected by computed tomography. There are no reported cases of this combination of thrombi. We hypothesized that the reason for this complication is the combination of coagulation disorder due to atopic dermatitis, silent myocardial infarction, and exacerbation of the coagulation abnormality due to bacteremia, leading to superior mesenteric vein and LV thrombosis. Atopic dermatitis that has potential risk factors of thrombus with sepsis could provoke thrombophilic state. Atopic dermatitis is a common disease, but continuous medical care is essential.

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.

Role of echocardiography for takotsubo cardiomyopathy: clinical and prognostic implications

Takotsubo cardiomyopathy (TTC) is newly-described secondary cardiomyopathy characterized by transient left ventricular (LV) dysfunction, which is increasingly recognized in the field of cardiology. TTC occurs in approximately 2% of the patients with acute coronary syndrome. Its onset is rare; however, its specific features play a crucial role in diagnosing the chest pain in clinical practice. TTC has generally favorable outcome with rapid recovery of LV function; however, an increasing evidence suggests that it should be regarded as a more serious acute cardiac disorder with a variety of complications. Owing to its widespread availability, even in emergency settings, transthoracic echocardiography plays a key role in the diagnostic assessment of TTC and contributes to an increased number of disease detection and incidence reports in contemporary clinical practice. This review focuses on the role of echocardiography in understanding the clinical prognostic implications in patients with TTC.

Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Background

Left ventricular (LV) thrombi during Takotsubo syndrome represent a potential complication and can be associated with cerebrovascular embolic events. The aim of this study was to evaluate the exact incidence, predictors, and management strategies of LV thrombi in patients with Takotsubo syndrome.

Methods and Results

We enrolled 541 consecutive patients in a multicenter international registry. Clinical features and echocardiographic data at admission, during hospitalization, and after 3 months were evaluated. Survival rates for long‐term follow‐up (mean 984±908 days) were recorded. Twelve Takotsubo syndrome patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern). All patients with LV thrombi were treated with oral anticoagulation therapy; however, 2 (17%) had a stroke before treatment initiation. These patients were characterized by a higher prevalence of ST‐elevation (56% versus 16%; P<0.001) and higher troponin I levels (10.8±18.3 ng/mL versus 3.5±4.3 ng/mL; P=0.001) as compared with those without LV thrombi. At multivariate analysis including age, sex, LV ejection fraction, ST‐elevation at admission, and apical ballooning pattern, troponin I level >10 ng/mL was the only predictor for LV thrombosis (hazard ratio 6.6, confidence interval, 1.01–40.0; P=0.04). After 3 months all LV thrombi disappeared. Oral anticoagulation therapy was interrupted in all patients except 1. At long‐term follow‐up, the survival rate was not different between patients with and without LV thrombi (84% versus 85%; P=0.99).

Conclusions

LV thrombi have a relatively low incidence among patients with Takotsubo syndrome and were detected in female patients with apical ballooning pattern and increased troponin levels. Oral anticoagulation therapy for 3 months seems reasonable in these high‐risk patients.

Usefulness of left ventricular strain analysis in patients with takotsubo syndrome during acute phase

BACKGROUND

Takotsubo syndrome (TTS) is peculiar clinical condition often resembling an acute coronary syndrome and mostly affecting postmenopausal women after a stressful trigger. TTS was initially thought to be a relatively benign condition. However, current data have shown it may be associated with considerable inpatient morbidity and carry a small, but important, mortality risk.

METHODS

We hypothesized that left ventricular (LV) regional and global longitudinal strain (GLS) assessed with 2D speckle tracking echocardiography could identify early systolic functional impairment and predict in-hospital cardiovascular events. We conducted a retrospective descriptive study reviewing patients with the discharge diagnosis of TCM between 2003 and 2016 at our institution.

RESULTS

One hundred patients with TSS met the Modified Mayo Clinic criteria. Using 2D speckle tracking echocardiography, two independent cardiologists assessed the LV GLS as well as the longitudinal strain (LS) of 7 individual segments [basal-septal (BS); mid-septal (MS), apical-septal (AS), apex, basal-lateral (BL), mid-lateral (ML), and apical-lateral (AL)]. The inter-observer variability was <5%. Mean age was 69.1 years, 87% were females, and 53% were African Americans. Mean initial LV EF was 32% ± 9.8%. In univariate analysis, patients with worse BL, ML, and GLS profiles (means: -5.7; -3.3, and -4, respectively) had higher in-hospital mortality (P < .05). Worse BL and ML profiles (means: -8.6 and -7.3, respectively) were associated with higher prevalence of MACE (major adverse cardiovascular outcomes) (P < .05). In a multivariate analysis, mid-lateral strain ≥ -7 and basolateral strain ≥ -10 were independent predictors of in-hospital mortality and MACE + in-hospital heart failure, respectively.

CONCLUSIONS

Assessment of LV global and segmental longitudinal strain by speckle tracking has important prognostic value in the acute phase of TTS. Additional large-scale studies will be needed to confirm our findings.

Comprehensive computational assessment of blood flow characteristics of left ventricle based on in-vivo MRI in presence of artificial myocardial infarction

BACKGROUND

Understanding the effects of cardiac diseases on the heart's functionality which is the purpose of many biomedical researches, directly affects the diagnostic and therapeutic methods. Myocardial infarction (MI) is a common complication of cardiac ischemia, however, the impact of MI on the left ventricle (LV) flow patterns has not been widely considered by computational fluid dynamics studies thus far.

METHODS

In this study, we present an insightful numerical method that creates an artificial MI on an image-based fluid-structure interactional model of normal LV to investigate its influence on the flow in comparison with the normal case. Seventeen different models were developed to evaluate the effects of location, percentage, myocardial material properties and dilation size of MI on the LV's performance, area strain, wall displacement, pressure-volume loop, wall shear stress and velocity field.

RESULTS

The results show that MI considerably changes blood flow features which are fully dependent on MI parameters. For the case of constant MI location, the effect of a decrease of infarcted myocardium stiffness, increase of dilation size and increase of MI percentage are mostly similar. Although the location differences of MI under other constant conditions have similar impact on the ejection fraction, they also lead to dissimilar variations in the LV flow pattern and other indicators.

CONCLUSIONS

The presented model showed a capable computational method for investigating various mechanical MI conditions with respect to cardiac flow pattern. The perspective of this model development seems to be an applicable tool for MI clinical diagnosis and prediction of complications related to MI.

Modern Imaging Techniques in Cardiomyopathies

Modern advanced imaging techniques have allowed increasingly more rigorous assessment of the cardiac structure and function of several types of cardiomyopathies. In contemporary cardiology practice, echocardiography and cardiac magnetic resonance imaging are widely used to provide a basic framework in the evaluation and management of cardiomyopathies. Echocardiography is the quintessential imaging technique owing to its unique ability to provide real-time images of the beating heart with good temporal resolution, combined with its noninvasive nature, cost-effectiveness, availability, and portability. Cardiac magnetic resonance imaging provides data that are both complementary and uniquely distinct, thus allowing for insights into the disease process that until recently were not possible. The new catchphrase in the evaluation of cardiomyopathies is multimodality imaging, which is purported to be the efficient integration of various methods of cardiovascular imaging to improve the ability to diagnose, guide therapy, or predict outcomes. It usually involves an integrated approach to the use of echocardiography and cardiac magnetic resonance imaging for the assessment of cardiomyopathies, and, on occasion, single-photon emission computed tomography and such specialized techniques as pyrophosphate scanning.

Takotsubo Cardiomyopathy With a Rapidly Resolved Left Ventricular Thrombus

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.

Transmitral thrombectomy to treat a patient with Takotsubo cardiomyopathy

A 68-year-old woman with a history of bipolar disorder was admitted to another hospital with a gastric ulcer. On admission, Takotsubo cardiomyopathy was suspected because her electrocardiogram was abnormal and the characteristic left ventricular wall motion was apparent. On hospital day 11, echocardiography revealed a thrombus in the apex of the left ventricle. She was transferred to our hospital and heparin treatment was commenced. On follow-up echocardiography, the left ventricular wall motion had normalized but thrombus mobility had increased. Thrombectomy was performed via a transmitral approach with endoscopic assistance. Endoscopy allowed excellent visualization of the intracardiac structure.

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

Background

Takotsubo 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 presentation

A 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.

Conclusion

Though 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 material

The online version of this article (doi:10.1186/s12872-017-0616-0) contains supplementary material, which is available to authorized users.

Contemporary Imaging in Takotsubo Syndrome

Transthoracic echocardiography is the first-line imaging modality for evaluating patients with Takotsubo syndrome (TTS). Beyond diagnosis, TTE enables detection of peculiar complications and is useful for risk stratification and management of patients with cardiogenic shock. Cardiac magnetic resonance can be used to detect myocardial edema typically associated with TTS and is helpful in the differential diagnosis with other disease states. Coronary computed tomography angiography can be performed as an alternative to coronary angiography to confirm coronary artery patency. Molecular imaging is a promising approach for identifying patients at increased risk of recurrence.

Incidence and predictors of stroke during the index event in an ethnically diverse Takotsubo cardiomyopathy population

Takotsubo cardiomyopathy (TTS) is a peculiar clinical condition often affecting postmenopausal women after a stressful trigger. The underlying mechanisms have not been completely elucidated but several hypotheses have been advanced, with catecholamine cardiotoxicity, microvascular dysfunction and coronary artery spasm each suggested to play a role. The incidence of stroke after TTS appears to range from 0% to 7.7%, and interestingly TTS has been described as both a cause and a complication of stroke. We sought to assess the incidence and predictors of stroke during the index event (peri-index event stroke) in a heterogeneous TTS population. We conducted a retrospective descriptive study reviewing patients who were discharged with a diagnosis of TTS from the Einstein Medical Center, Philadelphia, PA and Danbury Hospital, Danbury, CT in the period between 2003 and 2014. A total of Incidence and predictors of stroke during the index event in an ethnically diverse Takotsubo cardiomyopathy population 206 patients met the modified Mayo Clinic criteria and were included in the study. The patients' overall mean age was 67.8 years; 87% (n=179) were females and 25% (n=53) were African Americans. The following incidence rates were found: stroke 7%, in-hospital heart failure 26.7%, and in-hospital death 7%. On multivariate analysis independent predictors (expressed as odds ratios with 95% confidence intervals) of periindex event stroke were: i) African American race (OR 3.2, 95% CI 1.2-10.2, p=0.048); ii) hypertension (OR 10.5, 95% CI 1.3-88, p=0.03). ACE inhibitor use was a protective factor for developing peri-index event stroke (OR 0.15, 95% CI 0.04-0.5, p=0.001). There was a trend towards dual antiplatelet therapy (DAPT) being protective for stroke (OR 0.3, 95% CI 0.05-1.1, p=0.08). The incidence of peri-index event stroke was 7%. African American race and hypertension were found to be independent predictors of peri-index event stroke. Prospective clinical trials are needed to confirm these findings and to better determine the impact of hypertension as a risk factor for stroke and to assess the role of DAPT in preventing it.