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Transapical extirpation of a left ventricular thrombus in takotsubo cardiomyopathy
© Suzuki et al.; licensee BioMed Central Ltd. 2013
Received: 1 February 2013
Accepted: 15 April 2013
Published: 26 May 2013
A 58-year-old Japanese female was referred to our hospital. Although the electrocardiogram showed ST elevation, coronary angiography showed intact coronary artery. We diagnosed Takotsubo cardiomyopathy and a left ventricular thrombus. Anticoagulation was administered; however, the left ventricular thrombus had become mobile and protrusive. We extirpated the left ventricular thrombus via trans-apical approach. Left ventricular thrombus is rare in Takotsubo cardiomyopathy, but these patients are at a higher risk of thromboembolism, especially if the thrombi are mobile and protruding.
Takotsubo cardiomyopathy is a disease characterized by a reversible left ventricular wall motion abnormality. The prognosis is favorable if there is normalization of the wall motion abnormalities within a few weeks. Although some investigators have reported cases of thromboembolic complications, such as cerebral infarction with a left ventricular thrombus, no published guidelines exist for the management of Takotsubo cardiomyopathy with a left ventricular thrombus. We herein report a case of Takotsubo cardiomyopathy with a left ventricular thrombus that was successfully removed during surgery.
Additional file 1: The apical long-axis view demonstrated a thrombus. There was a mural thrombus. (WMV 271 KB)
Additional file 2: Echocardiography seven days later showed a mobile and protrusive thrombus.(WMV 295 KB)
Takotsubo cardiomyopathy is described as a reversible left ventricular apical wall motion abnormality with chest symptoms. Although ST segment elevation is present in the electrocardiogram and there is an abnormal pattern of ventricular contraction, there is a lack of significant coronary artery stenosis . The prognosis of Takotsubo cardiomyopathy is usually good, but serious complications, such as thromboembolism, can occur . It is well known that left ventricular thrombi often occur after a myocardial infarction. Patients with anterior myocardial infarction are at an especially high risk of left ventricular thrombus development. The formation of a thrombus can be consequence of increased infarct size, pump failure, severe apical asynergy and decreased global left ventricular function . In cases of Takotsubo cardiomyopathy, the ventricular dysfunction extends beyond a single coronary artery region. A left ventricular apical dysfunction resembling that of an aneurysm can occur. This is thought to be a possible cause of a left ventricular thrombus. Therefore, anticoagulation therapy is recommended for patients with Takotsubo cardiomyopathy. However, even under anticoagulation therapy, some investigators reported the incidence of left ventricular thrombus in the setting of Takotsubo cardiomyopathy to be 5.3–8% .
It is unknown whether thromboembolism is common in cases of Takotsubo cardiomyopathy. In cases of myocardial infarction, some authors have suggested that the thromboembolic risk was significantly higher in cases with thrombus protrusion and mobility . Thus, surgical extirpation is recommended to prevent thromboembolism. However, the area of myocardial infarction does not change the location where the thrombi generally occur. However, the wall abnormalities associated with Takotsubo cardiomyopathy are usually resolved within a few weeks. Upon normalization of the wall motion, if the left ventricular thrombus remains, the thromboembolic risk rate is high. In fact, some investigators have reported that thromboembolic complications occurred in 20–33.3% of the cases of Takotsubo cardiomyopathy [2–4]. Therefore, we performed surgical extirpation of the left ventricular thrombus, because it had morphologic features suggesting a high risk of thromboembolism. Seitz MJ and colleagues reported the case of Takotsubo cardiomyopathy related left ventricular apical thrombus requiring surgery . Also, they concluded surgical management of mobile and pedunculated left ventricular thrombus related to Takotsubo cardiomyopathy is warranted.
Early surgical extirpation is strongly recommended when a left ventricular thrombus in patients with Takotsubo cardiomyopathy becomes mobile and protrusive because of the high risk of thromboembolism.
Written informed consent was obtained from the patient for publication of this Case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
All participants of this study were provided appropriate informed consent, and the ethics review boards of Yamaguchi University Hospital approved the study design.
We greatly appreciate the assistance of the staff of the Department of Surgery and Clinical Science, Division of Cardiac Surgery, Yamaguchi University Graduate School of Medicine.
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