Intraventricular Thrombus Formation and Embolism in Takotsubo Syndrome

Emerging Trends in Left Ventricular Thrombus: A Comprehensive Review of Non-Ischemic and Ischemic Cardiopathies, Including Eosinophilic Myocarditis, Chagas Cardiomyopathy, Amyloidosis, and Innovative Anticoagulant Approaches

This comprehensive review explores the intricate aspects of left ventricular thrombus (LVT), a potential complication in both ischemic and non-ischemic cardiomyopathies. It provides a thorough understanding of left ventricular thrombus, revealing its uncommon incidence in the general population (7 cases per 10,000 patients), predominantly linked to ischemic heart diseases (ICMs) at an 80% prevalence rate. Diagnostic tools, notably transthoracic echocardiography (TTE) and cardiac magnetic resonance imaging (CMR), demonstrate varying sensitivity but remain indispensable in specific clinical contexts related to LVT as non-invasive diagnostic modalities. A detailed comparison between ICM patients and those with non-ischemic cardiomyopathy (NICM) who have left ventricular thrombus reveals subtle distinctions with significant clinical implications. This analysis underscores the importance of these imaging techniques in distinguishing between the two conditions. Additionally, we explored the occurrence of LVT in specific non-ischemic cardiomyopathies, including Takotsubo syndrome, hypertrophic cardiomyopathy, eosinophilic myocarditis, Chagas disease, cardiac amyloidosis, and several other conditions. The article further delves into anticoagulation strategies, thoroughly examining their impact on LVT regression and patient outcomes. Pharmacological interventions, with a focus on direct oral anticoagulants, emerge as promising alternatives; however, there is insufficient information on their efficiency and safety, especially in NICM population. In conclusion, this review highlights the complex nature of LVT, incorporating a range of etiopathogenic factors, diagnostic complexities, and evolving therapeutic approaches. It emphasizes the pressing need for ongoing research in this field.

The many faces of takotsubo syndrome: A review

Takotsubo syndrome is a state of an acute heart failure featuring reversible left ventricular dysfunction. In recent years, the incidence of Takotsubo syndrome has risen 8-fold. In this case series and literature review, we present the rare presentations or complications of Takotsubo syndrome and highlight diagnostic or management strategies. We aim to raise the awareness on the pathologic spectrum of takotsubo syndrome for the clinicians encountering this challenging diagnosis.

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.

Severe and Atypical Presentation of Takotsubo Cardiomyopathy in a Pediatric Patient after a Serious Crash Injury-Case Report and Literature Review

Takotsubo cardiomyopathy is an uncommon clinical entity in children, resulting in severe but sometimes reversible systolic dysfunction of the left ventricle. This condition is triggered by multiple emotional or physical stressors, while neurogenic stress cardiomyopathy after brain injuries has become increasingly recognized in children over the past few years. We report the case of an 11-year-old child with an atypical clinical presentation after a serious car crash accident. An initial computed tomography scan revealed an acute epidural hematoma, which was immediately treated by an emergency craniotomy. During the patient's following pediatric intensive care unit hospitalization, severe hemodynamic instability was observed, leading to gradually higher doses of vasopressors for circulatory support. On echocardiography, the patient had signs of severe cardiac contractility compromise, with characteristic pattern of regional wall motion abnormalities of the left ventricle, which, in combination with seriously elevated cardiac enzymes, electrocardiographic (ECG) abnormalities and continuous thermodilution hemodynamic monitoring (PICCO) findings, led to intensification of inotropic support and to the diagnosis of takotsubo cardiomyopathy. Despite supportive measures, the patient developed multiorgan failure and succumbed to their serious illness. For this atypical case, extracorporeal membrane oxygenation (ECMO) was addressed as an option for the seriously failing heart, but due to the extremely high risk of intracranial bleeding, it could not be used for this patient's treatment. In conclusion, Takotsubo cardiomyopathy should be suspected in pediatric cases of cardiac dysfunction after serious injuries or stress conditions.

Takotsubo syndrome: getting closer to its causes

Takotsubo syndrome (TTS) accounts for between 1 and 4% of cases presenting clinically as an acute coronary syndrome. It typically presents as a transient cardiac phenotype of left ventricular dysfunction with spontaneous recovery. More dramatic presentations may include cardiogenic shock or cardiac arrest. Despite progress in the understanding of the condition since its first description in 1990, considerable questions remain into understanding underlying pathomechanisms. In this review article, we describe the current published data on potential underlying mechanisms associated with the onset of TTS including sympathetic nervous system over-stimulation, structural and functional alterations in the central nervous system, catecholamine secretion, alterations in the balance and distribution of adrenergic receptors, the additive impact of hormones including oestrogen, epicardial coronary or microvascular spasm, endothelial dysfunction, and genetics as potentially contributing to the cascade of events leading to the onset. These pathomechanisms provide suggestions for novel potential therapeutic strategies in patients with TTS including the role of cognitive behavioural therapy, beta-blockers, and endothelin-A antagonists. The underlying mechanism of TTS remains elusive. In reality, physical or emotional stressors likely trigger through the amygdala and hippocampus a central neurohumoral activation with the local and systemic secretion of excess catecholamine and other neurohormones, which exert its effect on the myocardium through a metabolic switch, altered cellular signalling, and endothelial dysfunction. These complex pathways exert a regional activation in the myocardium through the altered distribution of adrenoceptors and density of autonomic innervation as a protective mechanism from myocardial apoptosis. More research is needed to understand how these different complex mechanisms interact with each other to bring on the TTS phenotype.

Direct Oral Anticoagulants for Stroke and Systemic Embolism Prevention in Patients with Left Ventricular Thrombus

In recent years, direct oral anticoagulants (DOAC) have accumulated evidence of efficacy and safety in various clinical scenarios and are approved for a wide spectrum of indications. Still, they are currently used off-label for left ventricular thrombus owing to a paucity of evidence. For the same reason, there is a lack of guideline indication as well. Our work is based on an exhaustive analysis of the available literature and provides a structured and detailed update on the use of DOACs in patients with left ventricle thrombus. The safety and efficacy of DOACs were analyzed in particular clinical scenarios. As far as we know, this is the first paper that analyzes DOACs in this approach.

Left Ventricular Thrombosis: Current Perspective and Use of Direct Oral Anticoagulants

Left ventricular thrombus (LVT) is a serious risk factor for systemic embolism development. Despite the evident danger of this condition, current guidelines describe management of patients with this potentially fatal complication very briefly. LVT can complicate myocardial infarction where its incidence is around 10%, as well as various forms of cardiomyopathies and novel coronavirus infection. According to clinical guidelines vitamin K antagonists (VKAs) should be used as treatment of choice for thrombus resolution. However, experts point out that this therapy lacks necessary evidential base and bears certain difficulties because of pharmacokinetic and pharmacodynamical properties of VKAs. These drawbacks are absent in direct oral anticoagulants (DOACs), the possibility of using which in LVT is being actively studied. As for now, published results of 3 randomised clinical trials have demonstrated similar safety and efficacy profiles of DOACs and VKAs. Similarly, the majority of retrospective cohort studies did not observe significant differences between two groups, where some of them have shown superiority of DOACs especially in terms of earlier thrombus resolution. Nevertheless, some studies have found DOACs ineffective and even potentially unsafe regarding systemic embolism. Existing data does not allow to form an unambiguous conclusion about the equivalence of DOACs and VKAs for LVT resolution. Large randomised clinical trials are needed to determine efficacy and safety of such treatment in these patients.

Management of Patients at Risk for and With Left Ventricular Thrombus: A Scientific Statement From the American Heart Association

Despite the many advances in cardiovascular medicine, decisions concerning the diagnosis, prevention, and treatment of left ventricular (LV) thrombus often remain challenging. There are only limited organizational guideline recommendations with regard to LV thrombus. Furthermore, management issues in current practice are increasingly complex, including concerns about adding oral anticoagulant therapy to dual antiplatelet therapy, the availability of direct oral anticoagulants as a potential alternative option to traditional vitamin K antagonists, and the use of diagnostic modalities such as cardiac magnetic resonance imaging, which has greater sensitivity for LV thrombus detection than echocardiography. Therefore, this American Heart Association scientific statement was commissioned with the goals of addressing 8 key clinical management questions related to LV thrombus, including the prevention and treatment after myocardial infarction, prevention and treatment in dilated cardiomyopathy, management of mural (laminated) thrombus, imaging of LV thrombus, direct oral anticoagulants as an alternative to warfarin, treatments other than oral anticoagulants for LV thrombus (eg, dual antiplatelet therapy, fibrinolysis, surgical excision), and the approach to persistent LV thrombus despite anticoagulation therapy. Practical management suggestions in the form of text, tables, and flow diagrams based on careful and critical review of actual study data as formulated by this multidisciplinary writing committee are given.

Update of Takotsubo cardiomyopathy: Present experience and outlook for the future

Takotsubo cardiomyopathy (TTS) has become a recognised clinical entity since the Japanese scientist Sato first described it in 1990.

Despite an increasing number of confirmed cases, especially during the COVID-19 pandemic, its pathophysiology remains incompletely understood, and decision-making differs in the diagnosis and treatment. In addition, it is not evident whether a significant increase in TTS is due to better understanding among practitioners and widespread access to coronary angiography, or if it is a reflection of an actual increase in incidence.

We analysed a series of international research studies from 1990 to 2021. Beyond epidemiology and clinical presentation, we evaluated and summarised fundamental knowledge about various predisposing factors, with particular attention to the iatrogenic impact of certain drugs, namely antidepressants, chemotherapy, and antiarrhythmics.

Furthermore, we highlighted the main pathophysiological theories to date. In addition, based on published studies and clinical cases, we investigated the role of numerous diagnostic approaches in the differential diagnosis of TTS and identified predictors of TTS complications, such as cardiogenic shock, ventricular fibrillation, and left ventricular thrombi. Accordingly, we sought to propose a diagnostic algorithm and further treatment management of TTS under the presence of possible complications to help practitioners make more informed decisions, as the initial presentation continues to pose a challenge due to its close similarity to acute coronary syndrome with ST-elevation.

In conclusion, this article examines Takotsubo cardiomyopathy from different perspectives and, along with future systematic reviews and meta-analyses, can be of particular interest to practising cardiologists and researchers in developing clinical guidelines.

Stepwise approach for diagnosis and management of Takotsubo syndrome with cardiac imaging tools

Takotsubo syndrome is featured by transient left ventricle dysfunction in the absence of significant coronary artery disease, mainly triggered by emotional or physical stress. Its clinical presentation is similar to acute coronary syndrome; therefore, cardiac imaging tools have a crucial role. Coronary angiography is mandatory for exclusion of pathological stenosis. On the other side, transthoracic echocardiography is the first non-invasive imaging modality for an early evaluation of left ventricle systolic and diastolic function. Left ventricle morphologic patterns could be identified according to the localization of wall motion abnormalities. Moreover, an early identification of potential mechanical and electrical complications such as left ventricle outflow tract obstruction, mitral regurgitation, thrombus formation, right ventricular involvement, cardiac rupture, and cardiac rhythm disorders could provide additional information for clinical management and therapy. Because of the dynamic evolution of the syndrome, comprehensive serial echocardiographic examinations should be systematically performed. Advanced techniques, including speckle-tracking echocardiography, cardiac magnetic resonance, and nuclear imaging can provide mechanistic and pathophysiologic insights into this syndrome. This review focuses on these aspects and provide a stepwise approach of all cardiac imaging tools for the diagnosis and the management of Takotsubo syndrome.

Anticoagulation in cardiomyopathy: unravelling the hidden threat and challenging the threat individually

Cardiomyopathy comprises a heterogeneous group of myocardial abnormalities, structural or functional in nature, in the absence of coronary artery disease and other abnormal loading conditions. These myocardial pathologies can result in premature death or disability from progressive heart failure, arrhythmia, stroke, or other embolic events. The European Cardiomyopathy Registry reports a high stroke risk in cardiomyopathy patients ranging from 2.1% to 4.5%, as well as high prevalence of atrial fibrillation ranging from 14.0% to 48.5%. There is a growing interest in evaluating the risk of thromboembolism depending on the type of cardiomyopathy, as well as if anticoagulation is indicated in patients with cardiomyopathy without atrial fibrillation. Data available do not unequivocally support anticoagulation therapy in all of these patients; the management of these patients remains challenging. Many published reports pertaining to the risk of thromboembolism and consecutive treatment strategies mainly focus on single cardiomyopathy subtype. We summarize essential pathophysiological knowledge and review current literature associated with thromboembolism in various cardiomyopathy subtypes, providing recommendations for the diagnostic evaluation as well as clinical management strategies in this field. Certain cardiomyopathy subtypes require anticoagulation independent of atrial fibrillation or CHA2 DS2 -VASc score. Despite the scarcity of evidence regarding the choice of anticoagulation regimen (vitamin K antagonist vs. non-vitamin K oral anticoagulants) in cardiomyopathy, it is discussed and reviewed in this article. Each patient should receive a tailored strategy based on thorough clinical evaluation, published evidence, and clinical experience, due to the current recommendations mostly developed on small-sample studies or empirical evidence. The future research priorities in this area are also addressed in this article.

Left ventricular thrombus on cardiovascular magnetic resonance imaging in non-ischaemic cardiomyopathy

AIMS

Case reports have described left ventricular (LV) thrombus in patients with non-ischaemic cardiomyopathy (NICM). We aimed to systematically study the characteristics, predictors, and outcomes of LV thrombus in NICM.

METHODS AND RESULTS

Forty-eight patients with LV thrombus detected on late gadolinium enhancement cardiovascular magnetic resonance imaging (LGE CMR) in NICM were compared with 124 patients with LV thrombus in ischaemic cardiomyopathy (ICM), and 144 matched patients with no LV thrombus in NICM. The performance of echocardiography for the detection of LV thrombus was compared between NICM and ICM. The 12-month incidence of embolism was compared between the three study groups. Independent predictors of LV thrombus in NICM were LV ejection fraction (LVEF) [hazard ratio (HR) 1.36 per 5% decrease; P = 0.002], LGE presence (HR 6.30; P < 0.001), and LGE extent (HR 1.33 per 5% increase; P = 0.001). Compared with patients with LV thrombus in ICM, those with LV thrombus in NICM had a 10-fold higher prevalence of thrombi in other cardiac chambers. The performance of echocardiography for the detection of LV thrombus was not different between NICM and ICM. The 12-month incidence of embolism associated with LV thrombus was not different between NICM and ICM (8.7% vs. 6.8%; P = 0.69) but both were higher compared with no LV thrombus in NICM (1.5%).

CONCLUSION

Independent predictors of LV thrombus in NICM were lower LVEF, LGE presence, and greater LGE extent. The 12-month incidence of embolism associated with LV thrombus in NICM was not different compared with LV thrombus in ICM.

Prognostic factors of Takotsubo cardiomyopathy: a systematic review

Takotsubo cardiomyopathy (TCM), characterized by reversible ventricular dysfunction, has similar mortality to acute coronary syndrome. With the growing interest in the diagnosis of and interventions for TCM, many risk factors had been found to affect the prognosis of TCM patients, such as age, sex, and pre-existing diseases. Because of the incomplete understanding of the pathophysiologic mechanism in TCM, evidence-based medical therapy for this condition is lacking. Early intervention on risk factors may improve the outcomes of TCM. In this review, we sought to provide up-to-date evidence on risk factors and medical therapies that affect TCM outcome. We found that male sex, physical triggers, and certain comorbidities such as chronic kidney disease, malignant disease, higher body mass index, sepsis, chronic obstructive pulmonary disease, and anaemia were associated with poor TCM prognosis. In contrast, race, hyperlipidaemia, diabetes mellitus, and mood disorders were not clearly associated with TCM prognosis. We also reviewed the effect of medical therapies on TCM outcome, including angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, calcium channel blockers, and statins. The evidence that these medications confer a survival benefit on TCM patients is limited. Understanding these prognostic factors could help develop risk-stratification tools for TCM and establish effective prevention and interventions for this not-so-benign condition. Further multicentre clinical studies with large samples and meta-analyses of findings from previous studies are needed to address the inconsistent findings among the many potential risk factors for TCM.

Takotsubo Syndrome: Optimizing Care with a Multidisciplinary Approach

Symptoms of takotsubo syndrome (TTS) include acute and transient regional systolic dysfunction of the left ventricle, as well as a variety of wall-motion abnormalities. The clinical features of TTS, including initial symptoms, cardiac biomarkers, and electrocardiogram (ECG) changes, are similar to those of acute coronary syndrome, with the exception that TTS patients typically have no obstructive coronary artery disease. TTS primarily affects elderly women, and emotional or physical stress is a common cause of the disease. Exaggerated sympathetic stimulation associated with dysfunction of the limbic system has also been reported to be related to TTS occurrence. Cancer also induces emotional and physical stress. Therefore, optimization of TTS care should involve cardiac, neurological, psychiatric, and oncological approaches. The first step in optimizing TTS care is to diagnose it by cardiac means. Multimodality imaging, including ECG, echocardiogram, angiography, ventriculography, and cardiac magnetic resonance imaging, is indispensable for diagnosis, therapy management, and the evaluation of prognosis in the acute and chronic phases of TTS. The current cardiac approach during the acute phase is primarily supportive, with the goal of preventing life-threatening complications. As central nervous system diseases frequently trigger TTS, a neurological approach is also required. Appropriate psychiatric medication may reduce the risk of TTS recurrence, as not only psychiatric disorders themselves but also psychiatric medications can be the trigger for TTS. Several conditions are associated with TTS, including the novel coronavirus disease 2019. We present current knowledge of TTS in this review and describe how to optimize TTS care through a multidisciplinary approach.

Reversible Takotsubo Syndrome Complicated With Acute Thromboembolic Stroke Co-Occurring With Cola-Induced Severe Hypokalemia

Takotsubo syndrome (TTS) is a poorly understood phenomenon that manifests as reversible myocardial damage. Despite the overall benign course of TTS, acute complications and significant mortality and morbidity are frequently encountered. However, the risk factors for developing such complications are not well determined. We present a case of reversible TTS within 48 hours after correction of cola-induced hypokalemia complicated by thromboembolic stroke. We present the patient's clinical presentation with imaging studies and discuss the case in light of related literature. A 62-year-old woman with a longstanding history of inadequate oral intake and excessively sweetened cola soft drinks consumption. Presented with progressive symmetrical quadriparesis and found to have severe hypokalemia with rhabdomyolysis, elevated troponin, and acute left ventricular dysfunction. The patient was diagnosed with TTS and hypokalemic paralysis. Her hospital course was complicated with an acute thromboembolic stroke of bilateral occipital lobes and left cerebellum. Takotsubo cardiomyopathy was reversible 48 hours after correction of severe hypokalemia. Cardiac ischemic workup was negative for any evidence of myocardial ischemia. In this presented case, TTS was revisable within 48 hours after the correction of cola-induced hypokalemia. However, patients with similar presentations might have a higher risk for in-hospital thromboembolic complications of TTS. 

Trends, Predictors and Outcomes of Ischemic Stroke Among Patients Hospitalized with Takotsubo Cardiomyopathy

OBJECTIVES

This study assessed the temporal trends in the incidence of ischemic stroke among patients hospitalized with takotsubo cardiomyopathy (TCM) stratified by the subtypes of ischemic stroke (cardioembolic versus thrombotic). Predictors of each stroke subtype, the association with atrial fibrillation (AF), the occurrence of ventricular fibrillation/ventricular tachycardia (VF/VT), cardiogenic shock (CS), in-hospital mortality, length of stay (LOS), and total healthcare cost were also assessed.

BACKGROUND

Ischemic stroke in TCM is thought to be primarily cardioembolic from left ventricular mural thromboembolism. Limited data are available on the incidence of thrombotic ischemic stroke in TCM.

MATERIALS AND METHODS

We identified 27,970 patients hospitalized with the primary diagnosis of TCM from the 2008 to 2017 National Inpatient Sample, of which 751 (3%) developed ischemic stroke. Of those with ischemic stroke, 571 (76%) had thrombotic stroke while 180 (24%) had cardioembolic stroke. Cochrane armitage test was used to assess the incidence of thrombotic and cardioembolic strokes and multivariate regression was used to identify risk factors associated with each stroke subtype. We compared the incidence of AF, VF/VT, CS, LOS, in-hospital mortality and total cost between hospitalized patients with TCM alone to those with cardioembolic and thrombotic strokes.

RESULTS

From 2008 - 2017, the incidence of thrombotic stroke (4.7%-9.5% (p< 0.0001) increased while it was unchanged for cardioembolic stroke (0.5%-0.7% P=0.5). In the multivariate regression, peripheral artery disease, prior history of stroke, and hyperlipidemia were significantly associated with thrombotic stroke, while CS, AF, and Asian race (compared to White race) were associated with cardioembolic stroke. Both cardioembolic and thrombotic strokes were associated with higher odds of IHM, AF, CS, longer LOS and increased cost. Trends in in-hospital mortality and the utilization of thrombolysis, cerebral angiography, and mechanical thrombectomy among patients with TCM and ischemic stroke were unchanged from 2008 to 2017.

CONCLUSION

Among patients with TCM and ischemic stroke, thrombotic stroke was more common compared to cardioembolic stroke. Ischemic stroke was associated with poorer outcomes, including higher in-hospital mortality and increased healthcare resource utilization in TCM.

Dynamic Left Intraventricular Obstruction Phenotype in Takotsubo Syndrome

Takotsubo syndrome (TTS) is characterized by acute, generally transient left ventricular (LV) dysfunction. Although TTS has been long regarded as a benign condition, recent evidence showed that rate of acute complications and in-hospital mortality is comparable to that of patients with acute coronary syndrome. In particular, the prevalence of cardiogenic shock ranges between 6% and 20%. In this setting, detection of mechanisms leading to cardiogenic shock can be challenging. Besides a severely impaired systolic function, onset of LV outflow tract obstruction (LVOTO) together with mitral regurgitation related to systolic anterior motion of mitral valve leaflets can lead to hemodynamic instability. Early identification of LVOTO with echocardiography is crucial and has important implications on selection of the appropriate therapy. Application of short-acting b1-selective betablockers and prudent administration of fluids might help to resolve LVOTO. Conversely, inotrope agents may increase basal hypercontractility and worsen the intraventricular pressure gradient. To date, outcomes and management of patients with TTS complicated by LVOTO as yet has not been comprehensively investigated.

Takotsubo Syndrome: Uncovering Myths and Misconceptions

PURPOSE OF REVIEW

Takotsubo syndrome (TTS) was described in Japan 3 decades ago to affect predominately postmenopausal women after emotional stress. This history is the basis of commonly held beliefs which may contribute to the underdiagnosis and misperception of TTS.

RECENT FINDINGS

TTS affects not only women, but can be present in both sexes, and can appear in children as well as in the elderly. TTS is characterized by unique clinical characteristics with morphological variants, and incurs a substantial risk for recurrent events and adverse outcomes. Physical triggers are more common than emotional triggers and are major disease determinants. TTS seems not to be completely transient as patients report ongoing chest pain, dyspnea, or fatigue even after months of the acute event. Knowledge of the clinical features and outcomes of TTS patients has evolved substantially over the past decades. The heterogeneous appearance of TTS needs to be recognized in all medical disciplines to maximize therapy and improve outcomes.

A case report of takotsubo syndrome complicated by ischaemic stroke: the clinical dilemma of anticoagulation

Background

Takotsubo syndrome (TTS) is an acute and transient heart failure syndrome due to reversible myocardial dysfunction characterized by a wide spectrum of possible clinical scenarios. About one-fifth of TTS patients experience adverse in-hospital events. Thromboembolic complications, especially stroke, have been reported, albeit in a minority of patients.

Case summary

A 69-year-old woman presented to our emergency department for dyspnoea after a family quarrel. Electrocardiogram revealed ST-segment elevation in anterolateral leads and laboratory exams showed a slight elevation of high-sensitivity cardiac troponin. The patient was treated according to current guidelines on ST-elevation myocardial infarction and referred to the cath lab. Urgent coronary angiography revealed normal coronary arteries. Based on the patient profile and instrumental findings, a diagnosis of TTS was hypothesized. After 6 days, the patient developed dysarthria and right hemiparesis under therapy with aspirin, whilst low molecular weight heparin had been previously withdrawn. Transthoracic echocardiography (TTE) revealed persisting apical akinesia and a subtle intraventricular thrombus. Head computed tomography and magnetic resonance imaging detected focal areas of ischaemic necrosis resembling diffuse cardioembolic lesions. Anticoagulation therapy was started and regular TTE showed complete recovery of myocardial systolic function and absence of ventricular thrombi at 1-month follow-up. The patient fully recovered speech after 5 months.

Discussion

This challenging case reinforces current recommendations to administer antithrombotic therapy in TTS patients with extensive apical dysfunction up to complete or near-complete recovery of myocardial contractility, regardless of the presence of atrial fibrillation, and highlights the importance of close TTE monitoring during the acute phase.

The Story of a Broken Heart: Takotsubo Cardiomyopathy

Licensed independent practitioners in emergency clinical practice are tasked with differentiating acute cardiac presentations. Despite its similarity in clinical presentation to acute coronary syndrome, Takotsubo cardiomyopathy is a unique cardiac disorder characterized by a stress-induced ballooning of the myocardium. Also known as the broken heart syndrome, Takotsubo cardiomyopathy most frequently occurs after an overwhelming emotional or physical stressor. The subsequent impaired contractility of the heart places the patient at risk of complications, including acute heart failure, cardiogenic shock, thromboembolism, arrhythmias, and left ventricular outflow obstruction. Takotsubo cardiomyopathy is similar in presentation to other cardiac disorders; therefore, clinicians in emergency settings must be efficient and effective in their diagnosis of this disorder on the basis of its distinct criteria. The current article uses most recent evidence to describe the etiology, pathophysiology, diagnosis, and recommended treatment for Takotsubo cardiomyopathy to support licensed independent practitioners in emergency departments in improving patient outcomes and reducing morbidity.

Management of left ventricular thrombus: a narrative review

Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.

Current Knowledge and Future Challenges in Takotsubo Syndrome: Part 2-Treatment and Prognosis

Takotsubo syndrome (TTS) represents a form of acute heart failure featured by reversible left ventricular systolic dysfunction. The management during the acute phase is mainly performed with supportive pharmacological (diuretics, ACE-inhibitors/angiotensin-receptor blockers (ARBs), anticoagulants, antiarrhythmics, non-catecholamine inotropics (levosimendan), and non-pharmacological (mechanical circulatory and respiratory support) therapy, due to the wide clinical presentation and course of the disease. However, there is a gap in evidence and there are no randomized and adequately powered studies on clinical effectiveness of therapeutic approaches. Some evidence supports the use ACE-inhibitors/ARBs at long-term. A tailored approach based on cardiovascular and non-cardiovascular risk factors is strongly suggested for long-term management. The urgent need for evidence-based treatment approaches is also reflected by the prognosis following TTS. The acute phase of the disease can be accompanied by various cardiovascular complications. In addition, long term outcome of TTS patients is also related to non-cardiovascular comorbidities. Physical triggers such as hypoxia and acute neurological disorders in TTS are associated with a poor outcome.

An extremely rare complication of acute pancreatitis: Intraventricular thrombus

Acute pancreatitis is a frequent reason for emergency admission, which has seen its numbers increase over the years. This condition has systemic, local, and vascular complications. A 73-year-old male patient presented to our emergency department complaining of abdominal pain, nausea, and vomiting. During imaging, intraventricular thrombus was discovered, and following completion of diagnostic testing, he was diagnosed with acute pancreatitis. Herein, we present the first case of intraventricular thrombus related to acute pancreatitis prothrombotic process in the literature.

A biventricular takotsubo cardiomyopathy complication: large thrombus formation to stroke in 150 min

A 67-year-old postmenopausal African American woman presented with biventricular takotsubo cardiomyopathy (TTC)-evidenced by transthoracic echocardiography (TTE) showing apical akinesis of both left and right ventricles in the absence of obstructive coronary artery disease on left heart catheterisation. On the 4th hospital day, she experienced acute left facial droop, dysarthria and dysphagia. CT of the head showed a wedge infarct of the right middle cerebral artery territory. Cardioembolism was presumed after intracranial and extracranial sources of thromboembolism were ruled out. Intravenous tissue plasminogen activator (tPA) was administered with resolution of symptoms. She was later discharged without neurological deficits. Crucially, repeat TTE after tPA infusion revealed a left ventricular mass concerning for thrombus. TTE 150 min prior to stroke onset was devoid of a mass. This case uniquely illustrates the potential for rapid thrombus formation and embolism in patients with TTC. As such, it emphasises the high index of suspicion required for management of these patients.

Left ventricular thrombosis: new perspectives on an old problem

Left ventricular thrombosis (LVT) is a major risk factor for systemic thromboembolism and might complicate both the acute and the chronic phase of ischaemic heart disease after myocardial infarction and, less frequently, non-ischaemic cardiomyopathies. The pathophysiology of thrombus formation is complex and involves the three aspects of Virchow's triad: blood stasis, prothrombotic state, and tissue injury. Advances in technology have improved the detection rate of intracardiac thrombi, but several uncertainties still remain regarding the optimal treatment strategy within daily clinical practice. Of note, anticoagulation therapy with heparin and vitamin K antagonists decreases the risk of embolic stroke though exposing patients to an undeniable risk of bleeding complications. Although limited data on the off-label use of direct oral anticoagulants have reported safety and efficacy for LVT resolution, yet more evidence is needed to justify their use in clinical practice.

Stress (Takotsubo) Cardiomyopathy: A Review of Its Pathophysiology, Manifestations, and Factors That Affect Prognosis

Stress (Takotsubo) cardiomyopathy (SC) is becoming an increasingly recognized syndrome, previously underdiagnosed due to its similar presentation to acute coronary syndrome (ACS). With advancements in imaging and diagnostic tools, our ability to recognize, diagnose and subsequently manage SC has advanced as well. Multiple diagnostic criteria have been created for the diagnosis of SC. While the diagnosis of SC does not always require imaging, advanced imaging can aid in the diagnosis of SC in unclear cases. However, due to the severity of ACS and the consequences of missing that diagnosis, SC is still typically a diagnosis of exclusion once ACS has been ruled out on cardiac catheterization. Our understanding of the pathogenesis of SC is still evolving. While catecholamine surges are widely believed to be the precipitating cause of SC, the exact mechanism for how catecholamine surges lead to ventricular dysfunction is still being debated. Understanding the mechanism behind ventricular dysfunction in SC can potentially provide the basis for treatment. Different stressors may lead to different variants of cardiomyopathy, with different portions of the ventricles affected. Treatment of SC is largely supportive and therefore should be tailored to the patient's individual needs based on the severity of presentation. Both the underlying stressor and the variant of SC affect time to recovery and mortality. Many patient factors can impact prognosis as well. Even after initial hospital discharge for SC, long-term risks do exist, including the risk for recurrent SC. Only angiotensin-converting enzyme inhibitors have been shown to reduce the recurrence of SC.