Abstract
Transient left ventricular apical hypokinesis results in a typical ampullary shape and has been described as Takotsubo cardiomyopathy (TCM). We report a case of TCM with the rare complication of left ventricular thrombus formation. Cardiac magnetic resonance imaging aided the diagnosis by characterizing the non-enhancing mass and evaluating the surrounding myocardium for scarring.
1 Introduction
Takotsubo cardiomyopathy (TTC), also known as transient left ventricular apical ballooning, is characterized by transient left ventricular dysfunction due to apical akinesis resulting in the typical ampullary shape, frequently mimicking appearance of acute coronary syndrome. [1] We describe a case of TCM with rare complication of left ventricular thrombus formation plus confirmation of this thrombus by cardiac magnetic resonance imaging (C-MRI).
2 Case report
A 74 year-old Caucasian male with history of hypertension and hyperlipidemia presented with right sided chest pain. The patient became very anxious after he realized he was locked outside of his car and started having chest pain. The patient was admitted for probable acute coronary syndrome. The electrocardiogram demonstrated ST elevation in precordial leads and leads I and III with peaked T waves in precordial leads. Cardiac markers were mildly elevated. Coronary angiography did not show significant coronary artery disease. However, left ventriculography revealed severe apical hypokinesis consistent with TCM and a reduced ejection fraction (EF) of 30%. (Fig.1 A-B).
Two weeks later, patient returned to his cardiologist and a transthoracic echocardiogram (TTE) was done which revealed improvement in left ventricular systolic function (EF 35–40%) with a partially mobile 20 × 15 mm mass protruding 25 mm from his left ventricular apex. (Fig. 1C) Normal wall motion of surrounding segments with hypokinesis of immediately adjoining myocardium was noted. Patient was then admitted for anticoagulation. C-MRI was performed five days later to identify the mass (tumor or thrombus) as well as to evaluate the myocardium for scarring. On imaging, a mobile 11.4 × 9.4 × 6.2 mm oval non-enhancing mass, consistent with a thrombus, was visible in the apex of the left ventricle with absence of surrounding myocardial infarction (MI). (Fig.2 A-C) Given the patient’s advanced age and lack of specific risk data for surgical thrombectomy in this setting, it was decided that surgery would only be pursued if anticoagulant therapy proved to be ineffective.
Serial follow-up TTEs demonstrated that the thrombus was gradually decreasing in size with increased mobility of left ventricle. Left ventricular ejection fraction was improving gradually. On final TTE, performed approximately seven weeks after initial identification of the thrombus, resolution of the thrombus with complete recovery of wall motion was noted and improved ejection fraction of 50%. (Fig. -2D)
3 Discussion
Although there are sparse case reports describing thrombus formation in TCM, this is the first report describing C-MRI features. [1] C-MRI was used to support the opinion that the mass was a thrombus and not a tumor. It also supported the diagnosis of TCM by demonstrating the absence of surrounding MI. [2] In 82–100% of TCM cases, the patients have been female. [1, 3, 4] This is the first case of TCM with thrombus formation in a male.
Another unusual feature of this case is that the thrombus was noted on the follow up echocardiogram but not seen on initial ventriculography. In all previous reports of thrombus formation, the thrombus was seen as a filling defect in ventriculography. [1, 3] Moreover, the size of this thrombus was quite large and had great mobility compared to previous reports. [1, 3] Of note, the C-MRI images revealed that the thrombus was round, not crescent shaped, which may suggest that this thrombus was acute in formation rather than a chronic process. Acute thrombi respond quicker to anticoagulation therapy as compared to chronic thrombi. This was demonstrated in our patient as it took only 7 weeks for the thrombus to resolve. The possible ramifications of a large pedunculated thrombus combined with rapidly improving left ventricular function, as seen with TCM, can be fatal due to embolization. Unlike wall motion abnormalities due to acute MI, the wall motion abnormalities in TCM are known to improve rapidly and completely. The implications are that when significant apical hypokinesis occurs with TCM, follow-up imaging with either TTE or C-MRI should be performed to rule out possible late thrombus formation and to evaluate for MI. [5–7] It is also important to recognize that cardiac catheterization in such patients should be performed with extreme caution to prevent emboli complications.
Abbreviations
- C-MRI:
-
Cardiac MRI
- MI:
-
Myocardial Infarction
- TCM:
-
Takotsubo Cardiomyopathy
- TTE:
-
Transthoracic Echocardiography
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Singh, V., Mayer, T., Salanitri, J. et al. Cardiac MRI documented left ventricular thrombus complicating acute takotsubo syndrome: an uncommon dilemma. Int J Cardiovasc Imaging 23, 591–593 (2007). https://doi.org/10.1007/s10554-006-9178-4
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DOI: https://doi.org/10.1007/s10554-006-9178-4