European Journal of Echocardiography 2007 8(6):491-494; doi:10.1016/j.euje.2006.08.001
Copyright © 2007, The European Society of Cardiology
An unusual presentation of "tako-tsubo cardiomyopathy"
Raffaele Iengoa,
Gemma Marrazzoa,
Salvatore Rumoloa,
Maria Accadiaa,
Maria Di Donatob,
Luigi Ascionea,* and
Bernardino Tuccilloa
aDivision of Cardiology, S. Maria di Loreto Hospital, Viale dei Pini 4, 80055 Portici, Naples, Italy
bDivision of Cardiology, G. Rummo Hospital, Benevento, Italy
Received 20 March 2006; received in revised form 23 July 2006; accepted after revision 11 August 2006.
* Corresponding author. Tel.: +39 0817755064; fax: +39 0812542752. luigi.ascione20{at}tin.it
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Abstract
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We report a case of tako-tsubo cardiomyopathy, complicated by
left ventricular apical thrombus.
Keywords: Tako-tsubo; Left ventricular apical thrombus
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Background
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"Tako-tsubo cardiomyopathy" is characterized by transient akinesis
of the mid and distal segments of left ventricular walls in
the absence of significant coronary artery disease.
1 Other features
include: chest pain, ischemic ECG abnormalities, prolonged QTc
interval and a mild increase of cardiac enzymes.
2 The first
patients were reported in Japan but this syndrome has now been
described both in the US and in Europe.
3,4 We report a woman
presenting with clinical, angiographic and echocardiographic
features of this syndrome, complicated by a left ventricular
apical thrombus.
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Case report
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A 76-year-old hypertensive woman with acute coronary syndrome
(ACS) was referred for emergency coronary arteriography from
another hospital where she was admitted with chest pain in relation
to acute emotional stress (the premature death of her daughter)
the day before and a significant ischemic ECG abnormalities
were documented. When she arrived to our clinic her blood pressure
was 120/70mmHg with a heart rate of 55bpm. On auscultation lungs
were clear, heart sounds were normal and no murmur or gallop
were noted. The ECG showed giant diffuse negative T waves with
a QTc interval of 500ms (
Fig. 1). Blood analysis showed a minor
increase of troponin values (troponin peak, 1.0ng/ml; normal
value, 0.04–0.2ng/ml) while creatine kinase (CK), CK-MB
and serum electrolytes were normal. Therapy with aspirin, intravenous
heparin, beta-blocker and GP IIb/IIIa inhibitor was started
and patient underwent emergency coronary arteriography. Coronary
arteries were normal with normal myocardial perfusion (
Fig. 2).
The diagnosis of ACS was rejected. We performed an echocardiogram
which showed normal global and regional left ventricular function
but a left ventricular apical mass was present in the four-chamber
apical view attached to the apex with an echodensity not different
from the surrounding myocardium. The ejection fraction was measured
at 60% (
Fig. 3). We contacted the referring hospital and learned
that they had performed an echocardiogram. This study showed
marked hypokinesis and akinesis of the mid and distal segments
of left ventricular walls, with hyperkinesis of the basal segments.
There was no left ventricular mass. The ejection fraction was
35% (
Fig. 4). Anticoagulant and beta-blockers therapy was continued.
Disorders potentially causing left ventricular dysfunction were
investigated. Blood tests revealed a mild increase of inflammatory
factors (sedimentation rate, C-reactive protein, beta-2-globulins).
One week later, echocardiography showed a reduction of the diameter
of apical thrombus which disappeared after 3 weeks of treatment
(
Fig. 5). The ECG returned to normal 3 months later (
Fig. 6).
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Figure 4 Four-chamber apical view recorded at the referring hospital showing a apical ballooning or "tako-tsubo" shape of the left ventricle as a result of the akinesis of the mid and distal segments of the left ventricular walls, with hyperkinesis of the basal segments.
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Discussion
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Tako-tsubo cardiomyopathy accounts for about 1–2% of all
patients presenting with symptoms suggesting ACS and occurs
predominantly in elderly women.
5 The underlying pathophysiology
remains unknown and several mechanisms have been proposed, including
multivessel epicardial spasm, myocardial dysfunction mediated
through catecholamine-induced damage, microvascular coronary
spasm or dysfunction and neurogenically mediated myocardial
stunning.
6 In the acute phase, pulmonary oedema, cardiogenic
shock, respiratory failure and arrhythmias may occur
7 but left
ventricular thrombus has been rarely reported.
8,9
The patient presented shows an apical thrombus associated with left ventricular apical ballooning. Thrombus formation was probably related to transient apical asynergy combined with an increased sympathetic activation related to acute mental stress. This lead to a hypercoagulable state mediated by combined alpha-2 and beta-2 adrenoreceptor-related mechanisms.10,11
In conclusion, despite a favourable prognosis of tako-tsubo cardiomyopathy reported in literature, it appears that life-threatening complications may occur.
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References
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- Stollberger C., Finsterer J., Schneider B. Tako-tsubo-like left ventricular dysfunction: clinical presentation, instrumental findings, additional cardiac and non-cardiac diseases and potential pathomechanisms. Minerva Cardioangiol (2005) 53:139–145.[Medline]
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- Kurisu S., Inoue I., Kawagoe T., Ishihara M., Shimatani Y., Nishioka K., et al. Left ventricular apical thrombus formation in a patient with suspected tako-tsubo-like left ventricular dysfunction. Circ J (2003) 67:556–558.[CrossRef][Web of Science][Medline]
- Steptoe A., Magid K., Edwards S., Brydon L., Hong Y., Erusalimsky J. The influence of psychological stress and socioeconomic status on platelet activation in men. Atherosclerosis (2003) 168:57–63.[CrossRef][Web of Science][Medline]
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Abstract
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