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

An incidental danger: Left ventricular thrombus in takotsubo syndrome

Takotsubo cardiomyopathy is a potentially lethal condition characterized by transient regional systolic dysfunction in the absence of coronary artery ischemia. This syndrome predominantly affects postmenopausal women and is often preceded by physical or emotional stress and often presents with symptoms of acute coronary syndrome, chest pain, and shortness of breath. Although the effects can be transient, takotsubo cardiomyopathy still results in an 8-12% rate of in-hospital mortality, with cardiogenic shock being the most common cause of death. There are known risk factors that increase the likelihood of a patient developing a left ventricular thrombus during the clinical course. The management of these cases is discussed in this report.

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.

A myasthenic crisis of broken hearts (reverse takotsubo): Case report and review of literature

Myasthenic crisis (MC) is rarely associated with takotsubo cardiomyopathy (TTC), but embolic complications of MC-associated reverse TTC are yet to be documented. We present a case of a 70-year-old Caucasian female with MC-associated reverse TTC, developing acute cerebral infarcts. Following aggressive treatment with immunoglobulins and anticholinergics, cardiac function normalised. TTC is an important differential diagnosis in acute deteriorations of cardiac function, particularly in intensive care, not only due to frequent use of inotropes and embolic complications but also because cardiac function is reversible with good medical care. Early specialist neurologist and cardiologist input should be sought in such cases.

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.

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.

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.

Takotsubo syndrome triggered by coronary artery embolism in a patient with chronic atrial fibrillation

Although takotsubo syndrome is defined as a reversible heart failure syndrome with the absence of obstructive coronary artery disease, some cases of concomitant takotsubo syndrome and acute myocardial infarction have been reported. We herein describe the case of a patient with chronic nonvalvular atrial fibrillation who was not receiving anticoagulant therapy, who developed takotsubo syndrome triggered by acute myocardial infarction probably due to coronary artery thromboembolism.

<Learning objective: Takotsubo syndrome triggered by acute myocardial infarction rarely occurs. Patients with a broad infarct-area require careful management because of the development of adverse events such as cardiogenic shock.>

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.

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

INTRODUCTION

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

CASE PRESENTATION

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

CONCLUSION

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

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

Takotsubo cardiomyopathy (TC) is a temporal dysfunction of the left ventricle (LV) due to psychological or physiological stress; however, it rarely causes LV thrombus. We report a case of a 49-year-old woman who developed LV thrombi due to TC despite anticoagulation therapy. The thrombi caused acute systemic infarction, with the most severe occlusion being in the right renal artery. The patient underwent percutaneous catheter aspiration thrombectomy of the right renal artery and her renal function recovered shortly after. The results of this case suggest that catheter aspiration thrombectomy is effective in the treatment of thromboembolism in TC.

Sudden death in a case of recurrent Takotsubo syndrome

Herein we report an unusual case of sudden death occurring in a 65 year old woman during a minor oral surgery. The subject, who had a medically treated anxiety, had a history of two reversible left ventricle dysfunction episodes consistent with recurrent Takotsubo Syndrome that had occurred seven and six years before, respectively. She also suffered from moderate, well treated post-menopausal systemic hypertension. Post-mortem examination showed apical biventricular ballooning of the heart with no cardiac rupture, coronary artery lesion or other cardiac/extra-cardiac disease. Toxicological tests and forensic investigations excluded unnatural causes of death, including pharmacological or iatrogenic causes related to medical malpractice. Only non-specific contraction bands and mild hypertrophy were observed by histology in the left ventricle myocytes. Takotsubo syndrome is usually an acute and reversible heart failure syndrome with acute left ventricle apex ballooning, no coronary artery disease or other macroscopic or microscopic cardiac changes; physical or emotional stress are well known triggering factors. Nevertheless, recurrent forms, major cardiac adverse events and even sudden death may occur in a minority of cases, meaning that a diagnosis of Takotsubo syndrome must be considered in cases of sudden death and in forensic investigations.

Cardiac and Systemic Thrombus Caused by Drug Abuse

Drug abuse is an increasing concern all over the world especially in the United States. Methamphetamine have been well established to cause elevated body temperature, irregular heartbeat, seizures, and heart disease. We present a case of ventricular thrombus with systemic emboli in a patient with dilated cardiomyopathy after methamphetamine use.

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.

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

A 56-year-old healthy male with no obvious risk factors or significant past medical history was admitted to the emergency room with acute ischemic stroke. On his transthoracic echocardiography (TTE), an extremely large thrombus was detected at the apex involving the distal anterior wall. The thrombus was predominantly adherent but with a mobile tip. The patient was subsequently managed with dual antiplatelet therapy. In this report, we present an interesting case of an acute ischemic stroke secondary to a giant left ventricular thrombus in a patient with no past significant cardiac or neurologic medical history.

Stress-induced thrombus: prevalence of thromboembolic events and the role of anticoagulation in Takotsubo cardiomyopathy

Background

Takotsubo cardiomyopathy (TCM), also known as stress-induced cardiomyopathy has a favorable prognosis with expected recovery in weeks. Left ventricular (LV) thrombus is a known complication of TCM, which can lead to embolization and potentially a stroke. The prevalence of LV thrombus and the role of anticoagulation have yet to be fully defined in this condition.

Methods

We performed a search of published literature through PubMed and Scopus, which identified 282 patients with TCM in whom the incidence of LV thrombus and/or thromboembolic event was reported. In order to contrast this to the current anticoagulation strategy of atrial fibrillation, the occurrence of LV thrombus was compared to the adjusted stroke rate using the CHADS2 score.

Results

Of the 282 patients identified through a literature search, 26 (9.2%) were noted to have a thromboembolic event in the setting of TCM. The incidence of thromboembolic event ranged from 5.3% to as high as 14.3%. When compared to the CH2sDS2-VASc score, the average incidence of LV thrombus in our study equated to a score between 4 and 5.

Conclusions

While the occurrence of LV thrombus in TCM is variable among studies, the average incidence remains relatively high. Thus, making LV thrombus a significant complication of stress-induced cardiomyopathy. Prophylactic anticoagulation until recovery may have a role in reducing the rate of LV thrombus. Further studies will be needed to determine the rate of embolization and utility of anticoagulation in TCM.

Evaluation of therapy management and outcome in Takotsubo syndrome

Background

To date there is no validated evidence for standardized treatment of patients with Takotsubo syndrome (TTS). Medication therapy after final TTS diagnosis remains unclear. Previous data on patient outcome is ambivalent. Aim of this study was to evaluate medication therapy in TTS and to analyze patient outcome.

Methods

Within an observational retrospective cohort study we analyzed our medical records and included 72 patients with TTS that underwent cardiovascular magnetic resonance imaging (CMR) after a median of 2 days interquartile range (IQR 1–3.5). We investigated medication therapy at discharge. Medication implementation and major adverse clinical events (MACE) were prospectively evaluated after a median follow-up of 24 months (IQR 6–43). Left ventricular function, myocardial oedema and late gadolinium enhancement were analyzed in a CMR follow-up if available.

Results

Antithrombotic therapy was recommended in 69 (96%) patients including different combinations. Antiplatelet monotherapy was prescribed in 28 (39%) patients. Dual antiplatelet therapy was recommended in 29 (40%) patients. Length of therapy duration varied from one to twelve months. Only in one case oral anticoagulation was prescribed due to apical ballooning with a left ventricular ejection fraction <30%. In all other cases oral anticoagulation was recommended due to other indications. ß-adrenoceptor antagonists and ACE inhibitors were recommended in 63 (88%), mineralocorticoid receptor antagonists were prescribed in 31 (43%) patients. After a median of 2 months (IQR 1.3–2.9) left ventricular function significantly recovered (49.1% ± 10.1 vs. 64.1% ± 5.7, P < 0.001) and myocardial oedema significantly decreased (13.5 ± 11.3 vs. 0.6% ± 2.4, P = <0.001) in the CMR follow-up. The 30-day mortality was 1%. MACE rate after 24 months was 12%.

Conclusion

Although therapy guidelines for TTS currently do not exist, we found that the majority of patients were treated with antithrombotic and heart failure therapy for up to twelve months. Left ventricular function and myocardial oedema recovered rapidly within the first two months. Outcome analysis showed a low bleeding rate and a high short-term survival. Therefore, TTS patients might benefit from antithrombotic and heart failure therapy at least for the first two months.