Canadian Journal of Cardiology 30 (2014) 1732.e9e1732.e11 www.onlinecjc.ca

Case Report

Embolus From Probable Takotsubo Cardiomyopathy: A Bedside Diagnosis Carmen Hrymak, MD, Shuangbo Liu, MD, Joshua Koulack, MD, MSc, FRCPS, Duane J. Funk, MD, FRCPC, S. Allan Schaffer, MD, FRCPC, and James W. Tam, MD, FRCPC, FACC University of Manitoba, Winnipeg, Manitoba, Canada

ABSTRACT

  RESUM E

A 59-year-old woman with stroke and thromboembolic aortoiliac disease in the setting of profound stress was found to have severe left ventricular (LV) systolic dysfunction and large mobile clot on focused cardiac ultrasonography (FCU). Marked recovery of LV function and thrombus resolution within 4 days suggested resolving Takotsubo cardiomyopathy. The role of FCU in early diagnosis and treatment is outlined here.

chocardiographie (Écho) cible e, nous avons observe  une dysfoncÀ l’e tion systolique grave du ventricule gauche (VG) et un caillot flottant volumineux chez une femme de 59 ans souffrant d’une maladie thrombo-embolique aorto-iliaque qui a subi un accident vasculaire re bral. Le re tablissement notable de la fonction VG et la re sorption ce re  la re mission de du thrombus dans les 4 jours qui ont suivi ont sugge la cardiomyopathie de Takotsubo. Nous exposons ci-après le rôle de e dans le diagnostic et le traitement pre coces. l’Écho cible

Case Presentation A 59-year-old woman with previously normal left ventricular (LV) function seen on previous echocardiograms presented after being trapped in her apartment next to a radiator for 3 days. She denied chest discomfort or other cardiac ischemic symptoms. There was a history of a psychiatric disorder requiring haloperidol, lorazepam, and venlafaxine, but no history of diabetes, hypertension, or substance abuse. Her blood pressure was 151/85, with sinus tachycardia at 110; she had a normal cardiac examination and absence of heart failure. Elevated creatine kinase (peak, 78,674 U/L), myoglobin (peak, 77,112 mg/L), and high-sensitivity (hs) troponin levels (peak, 437 ng/L) were noted, with gradual and slow decline of the latter (Supplemental Fig. S1) in a pattern not consistent with myocardial infarction. Diagnosis on presentation included acute partial-thickness burns, rhabdomyolysis, and multifocal nonhemorrhagic areas of cerebral infarcts identified on magnetic resonance imaging (MRI), with an embolic cause favoured. On the first night of admission, loss of femoral pulses led to computed tomographic angiography demonstrating

an acute occlusion of the lower abdominal aorta, both common iliac arteries, and right external and internal iliac arteries (Fig. 1). Emergency bilateral transfemoral aortoiliac thrombectomies were performed. Transient T-wave inversion in V2-V6 was present (Fig. 2A) with no evolutionary changes of infarction. Focused cardiac ultrasonography (FCU) performed postoperatively revealed severe LV dysfunction with a large mobile LV thrombus (LVT) (Fig. , view video online). 2, B and C; Videos 1 and 2 Systemic anticoagulation with intravenous unfractionated heparin was administered. Repeated aortic occlusion necessitated return to the operating room for repeated thrombectomy on day 2 after admission. Interestingly, before the second operation, the left ventricle was free of clot, suggesting embolization during the time when the activated partial thromboplastin time was therapeutic (85.7 seconds). There was significant improvement in ventricular function on day 4, with no residual LVT on repeated , view video online) echocardiography (Video 3 without the use of angiotensin-converting enzyme inhibitors or b-blockers in the interim. Electrocardiographic (EKG) changes eventually returned to baseline (Fig. 2D) with no evidence of atrial fibrillation on echocardiography or telemetry monitoring. The degree of transient but severe LV dysfunction was not consistent with the modest elevation in hs troponin. The diagnosis of transient stressrelated (Takotsubo) cardiomyopathy with thrombus and embolization was considered.

Received for publication July 16, 2014. Accepted August 18, 2014. Corresponding author: Dr Carmen Hrymak, T258, Old Basic Sciences Building, 770 Bannatyne Ave, Winnipeg, Manitoba R3T2N2, Canada. Tel.: þ1-204-803-4598; fax: þ1-204-789-3515. E-mail: [email protected] See page 1732.e11 for disclosure information.

http://dx.doi.org/10.1016/j.cjca.2014.08.008 0828-282X/Ó 2014 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

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Figure 1. Computed tomographic angiograph of aortoiliac occlusion.

LV dysfunction was more global than classic in our patient, with mild relative sparing of the basal constrictors. Angiography was not performed in the acute phase of illness because of active comorbidities. Because of rapid and apparent spontaneous recovery of LV function, the attending team and cardiology consultants felt that angiography would be of purely academic interest without clinical utility to the patient. No underlying hypercoagulable disorder or malignancy was identified on workup. Echocardiography at 4 weeks and cardiac MRI with delayed gadolinium enhancement at 7 weeks showed complete resolution of the ventricular dysfunction without scar formation. Systemic anticoagulation was continued for 1 month and was discontinued because of excessive bleeding. The patient remained on antiplatelet treatment and continues to rehabilitate slowly without evidence of recurrent cardiac or embolic concerns 5 months later.

Canadian Journal of Cardiology Volume 30 2014

Discussion Takotsubo cardiomyopathy is characterized by transient systolic dysfunction precipitated by physical or emotional stress, often with EKG changes and a minimal rise in enzyme levels and may account for 1%-3% of patients who initially appear to have acute coronary syndrome.1-3 In our patient, recovery of ventricular function occurred much earlier than in previous reported cases.1,3 Takotsubo cardiomyopathyeassociated LVT may have previously been underappreciated owing to the use of ventriculography as the primary method of diagnosis.1 The incidence of LVT is likely still underestimated because of a low index of suspicion and therefore incomplete workup for thrombus. In some studies, overestimation caused by reporting bias is possible. It appears that the incidence of LVT in patients with Takotsubo cardiomyopathy is between 5% and 8%.1,3,4 This is less that in patients with acute myocardial infarction, who have an incidence between 8% and 20%.3 In a systematic review, the incidence of LVT was 5%.1 One third of the patients with thrombus had embolic events, and they were more frequent in women > 65 years and patients with negative T-waves on admission.1 In a retrospective review of 52 patients with Takotsubo cardiomyopathy, 8% had thrombi, which most often occurred at initial presentation but took as long as several weeks to arise in some patients.4 In 95 patients with weekly echocardiography performed until LV function improved, 5 (5.3%) had LVT and 1 had a cerebral embolic event.3 The role of prophylactic systemic anticoagulation in Takotsubo cardiomyopathy remains uncertain. Recommendations to consider anticoagulation in patients at higher risk of thrombus formation have been proposed.1 Despite therapeutic anticoagulation, our patient had a second embolic event. As LV function improved, the existing thrombus may have become increasingly mobile and embolized. Recurrent embolic events despite anticoagulation have only very rarely

Figure 2. (A) T-wave inversion V2-V6. (B) Left ventricular thrombus (LVT) apical view. (C) LVT short-axis view. (D) Electrocardiographic resolution.

Hrymak et al. Embolus from Probable Takotsubo Cardiomyopathy

been described and in severe circumstances may require surgical embolectomy. This was not considered in our patient with only 1 repeated event and no residual LVT. FCU early in this patient’s management revealed the diagnosis of LVT and LV dysfunction and confirmed the management course. The severity of the patient’s condition and the nocturnal timing of care precluded immediate formal echocardiography. This application of FCU follows the American Society of Echocardiography recommendation that FCU-facilitated physical examination direct clinical management when urgent echocardiography is not readily available.5 In conclusion, in a patient of suitable characteristics and with a precipitant stressor presenting with unexplained neurologic or ischemic phenomena, the diagnosis of Takotsubo cardiomyopathy and LVT should be entertained. In patients at increased risk of embolic complications, therapeutic anticoagulation may be considered prophylactically even before LVT formation. Finally, the use of timely FCU should be considered as an important adjunct to physical examination, formal echocardiography, and other imaging modalities. Disclosures The authors have no conflicts of interest to disclose.

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References 1. De Gregorio C. Cardioembolic outcomes in stress-related cardiomyopathy complicated by ventricular thrombus: a systematic review of 26 clinical studies. Int J Cardiol 2010;141:11-7. 2. Bybee KA, Prasad A. Stress-related cardiomyopathy syndromes. Circulation 2008;118:397-409. 3. Kurisu S, Inoue I, Kawagoe T, et al. Incidence and treatment of left ventricular apical thrombosis in Tako-tsubo cardiomyopathy. Int J Cardiol 2011;146:e58-60. 4. Haghi D, Papavassiliu T, Heggemann F, et al. Incidence and clinical significance of left ventricular thrombus in tako-tsubo cardiomyopathy assessed with echocardiography. QJM 2008;101:381-6. 5. Spencer KT, Kimura BJ, Korcarz CE, et al. Focused cardiac ultrasound: recommendations from the American Society of Echocardiography. J Am Soc Echocardiogr 2013;26:567-81.

Supplementary Material To access the supplementary material accompanying this article, visit the online version of the Canadian Journal of Cardiology at www.onlinecjc.ca and at http://dx.doi.org/10. 1016/j.cjca.2014.08.008.

Embolus from probable Takotsubo cardiomyopathy: a bedside diagnosis.

A 59-year-old woman with stroke and thromboembolic aortoiliac disease in the setting of profound stress was found to have severe left ventricular (LV)...
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