Rapid Formation of Left Ventricular Giant Thrombus With Takotsubo Cardiomyopathy
A 54-year-old woman diagnosed with sarcoidosis with lung involvement was admitted because of faintness associated with complete atrioventricular block. Cardiac catheterization showed normal coronary arteries and preserved left ventricular systolic function (online-only Supplemental Movie I), but endomyocardial biopsy revealed cardiac involvement. A pacemaker was implanted uneventfully, but she perceived the operation to be particularly stressful. Three hours after the operation, routine follow-up echocardiography revealed akinesis of the left ventricular apical wall, but no apical thrombi (Figure 1; Supplemental Movies II and III). She had no symptoms, but her ECG showed artificial right ventricular apical pacing of 70 bpm with additional ST-segmental elevation in leads II, III, aVF, and V3 through V6. There were no significant changes in serum markers of cardiac damage (white blood cells, creatine kinase, creatine kinase-MB, and cardiac troponin T), but brain natriuretic peptide was elevated to 680 pg/mL (reference range <40 pg/mL). Coronary angiography performed 2 days after the operation revealed normal coronary arteries, but left ventriculography demonstrated apical and mid–left ventricular ballooning with augmented contraction of the basal segment, indicating that she was suffering from emotional stress–induced Takotsubo cardiomyopathy. Surprisingly, a giant thrombus, which had formed within 2 days, was detected at the apex (Figure 2; Supplemental Movies IV and V). Heparin and warfarin were started concurrently. Fortunately, the thrombus completely disappeared within 7 days, and left ventricular function recovered within 14 days, without any embolic events (Supplemental Movie VI). To the best of our knowledge, this is the first description of Takotsubo cardiomyopathy associated with rapid formation of an apical giant thrombus. Clinicians should note the possibility of rapid thrombus formation and consider the use of anticoagulation therapy in the management of Takotsubo cardiomyopathy.
The online-only Data Supplement, which contains Movies I through V, can be found at http://circ.ahajournals.org/cgi/content/full/115/23/e620/DC1.