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Prompt resolution of an apical left ventricular thrombus in a patient with takotsubo cardiomyopathy

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Abstract

This report describes the prompt resolution of an apical left ventricular (LV)-thrombus complicating transient apical ballooning in a 74-year-old woman. The patient was admitted to our emergency department with acute chest pain and ST-elevation on the electrocardiogram. Coronary angiography showed normal coronary arteries and LV-angiography demonstrated the presence of apical ballooning akinesis associated with basal hypercontraction. Echocardiography and MRI studies confirmed the presence of LV-apex akinesis and detected an apical thrombus. Follow-up echocardiography on day 12 before discharge of the patient, revealed a marked improvement of regional contractility of the LV-apex and surprisingly the complete resolution of the LV-apical thrombus. The patient was diagnosed with takotsubo cardiomyopathy.

Introduction

Transient left ventricular (LV)-dysfunction characterized by apical ballooning akinesis and hypercontraction of the basal segments is referred to as takotsubo cardiomyopathy [1], [2]. Its clinical manifestation closely resembles that of acute myocardial infarction, including acute onset of chest pain and ST-elevation on the electrocardiogram. In contrast to acute myocardial infarction, patients with takotsubo cardiomyopathy exhibit normal coronary angiography and mild increased cardiac enzymes that are disproportionate to the extent of akinesia. The LV-dysfunction usually resolves without any specific treatment. Takotsubo cardiomyopathy has been reported to have an incidence of 0.2% of all cases undergoing diagnostic coronary angiography in western Europe. This disorder predominantly affects elderly women and has been associated with emotional stress and with chronic pulmonary disease as predisposing factors [3], [4]. However, the precise cause of takotsubo cardiomyopathy remains to be determined.

Section snippets

Case report

A 74-year-old woman was admitted to our emergency department due to first occurrence of chest pain. The ECG showed ST elevation in leads II, III, aVF, and V1 to V5 and troponin T on admission was 0.31 μg/l. Emergency coronary angiography showed normal epicardial coronary vessels. LV-angiography demonstrated the presence of severe apical ballooning akinesis associated with basal hypercontraction and the patient was suspected to have takotsubo cardiomyopathy. Echocardiography performed on day 3,

Discussion

This case demonstrates a potential early complication of takotsubo cardiomyopathy by the formation of an LV-thrombus in a patient without history of heart failure or coronary artery disease. The LV-thrombus was detected by both MRI and by echocardiography, and resolved promptly within 9 days without the administration of lytic therapy and without causing thromboembolic complications. Furthermore, the LV-apex showed reversible ballooning akinesis which could be accurately predicted by MRI.

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