Stress Cardiomyopathy Complicated By Left Ventricular Thrombosis with Fatal Detachment

Abstract

Left ventricular thrombosis (LVT) in stress cardiomyopathy or Takotsubo syndrome (TTS) is a moderately frequent complication. However, cardioembolic events are not frequently reported. Herein, we present a case report of 80-year-old patient admitted for chest pain at rest, started few days earlier following a violent argument. Her medical history included arterial hypertension and recent surgery of descending colon adenocarcinoma. Electrocardiogram showed sinus rhythm, negative T waves from V1 to V6, in D2, D3, AVF, and long QTc. Laboratory examinations documented an increased high sensitivity Troponin I, myoglobin, creatine kinase-MB, and B-type natriuretic peptide. Transthoracic echocardiography (TTE) showed a reduced left ventricular (LV) ejection fraction, "apical ballooning" with hyperkinesis of the basal segments of LV, suggestive for stress cardiomyopathy. A large thrombus in LV apex (3.3 cm × 2.1 cm) was found. Coronary angiogram showed normal coronary arteries. Anticoagulant therapy with Warfarin was quickly started, bridging with unfractionated heparin. Cardiac surgery was excluded for high-risk surgical patient. Daily TTE monitoring was done with evidence of slight reduction of the LVT. After 7^th day from admission, the patient complained an intense and sudden pain in lower extremities bilaterally. An acute occlusion of the descending aorta just above the bifurcation in the common iliac arteries was found. Interventional radiology procedure of recanalization of the bis-iliac carrefour was successfully performed. However, few hours after the procedure, the patient's hemodynamic conditions worsened until the exitus.

Keywords: Acute thrombosis of descending aorta; anticoagulation; left ventricular thrombosis; stress cardiomyopathy; takotsubo syndrome.

Figure 1

Echocardiographic images (apical 4 chambers view) of thrombotic stratification in LV apex and its evolution at day 1 (a), 3 (b), and 7 (c)

Figure 2

Contrast-enhanced angio-computed tomography (CT) images showing acute total occlusion of the abdominal aorta just above the bis-iliac carrefour (red arrow); (a) coronal, (b) sagittal, (c) 3D CT scans

Figure 3

Angiographic images. Through retrograde access into left common femoral artery, contrast medium was injected documenting total obstruction upstream of the left common iliac artery (a) and a balloon catheter was placed. Subsequently, through access into right common femoral artery, an occlusion upstream of the vessel was documented (b). With a hydrophilic guidewire, the obstruction was overcome, Alteplase diluted in saline was released in the lumen of the subrenal abdominal aorta and thromboaspiration with PENUMBRA Kat 8 was performed. At the end of the procedure, patency of the subrenal abdominal aorta, iliac arterial axis, and common femoral artery bilaterally was documented (c)

Figure 4

Timeline of case report. LV = Left ventricular, VKA = Vitamin K antagonists, TTE = Transthoracic echocardiography