Review
Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: A systematic review

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Abstract

Background

Though a severe left ventricular systolic dysfunction has been described in most patients with Takotsubo-like (or Apical Ballooning) syndrome, the occurrence of intra-cavitary thrombus formation seems to be such an exceptional finding. However, no large studies but single case descriptions of this complication are available over the last decade in the literature.

Methods

By searching for the PubMed-Medline database we selected 14 studies that met our eligibility criteria.

Results

Demographic, clinical and morphofunctional characteristics of 15 patients who where described to have left ventricular thrombosis as a complication of the Takotsubo-like syndrome are comprehensively described in this review. Cardioembolic complications (stroke in 3 cases, renal infarction or popliteal artery thrombosis in other two) occurred in 33.3% out of them.

The incidence of thrombus formation and related systemic embolisms in the general population with this syndrome were established on the basis of such available historical data and reviews on this subject.

Conclusion

Left ventricular thrombus formation has been reported in at least 14 studies (15 patients) over the last decade until the end of 2007. This approximately results in about 2.5% of all the patients with documented Takotsubo-like syndrome. Cardioembolic complications occurred in 5/15 cases, corresponding to 0.8% of the whole known population.

Introduction

Apical ballooning or Takotsubo-like cardiomyopathy (also described as “phenomenon” or “syndrome”) is a rare acquired disease characterized by acute left ventricular systolic dysfunction in the lack of significant coronary artery obstruction. Essentially occurring in post-menopausal women, transient adrenergic-based (either, structural or functional) myocardial impairment, triggered intense, but also trivial (usually repetitive), emotional stress is believed to be the main pathophysiologic mechanism [1], [2], [3], [4], [5].

Though the lack of time-honoured diagnostic criteria, at least 4 points have been proposed by Bybee et al. [5] from the Mayo Clinic in 2004 to identify the patients with the syndrome: i) transient akinesis or dyskinesis of the left ventricular apical and mid-ventricular segments with regional wall-motion abnormalities extending beyond a single epicardial vascular distribution; ii) absence of obstructive coronary disease or angiographic evidence of acute plaque rupture; iii) new electrocardiographic abnormalities (either ST-segment elevation or T-wave inversion); iiii) absence of recent significant head trauma, intracranial bleeding, pheochromocytoma, obstructive epicardial coronary artery disease, myocarditis, hypertrophic cardiomyopathy.

In spite of the severe systolic dysfunction, usually recognised in association with apical dilatation that simulates an acute myocardial infarction, left ventricular thrombus formation (LVTF) has been rarely described as a complication of the disease.

In this study we sought to recognize and summarize the available literature data on this subject, in an attempt to provide the demographic and morphofunctional characteristics of the patients with LVTF and related clinical complications.

Section snippets

Literature search and data assessment

We reviewed all the published cases by searching for the MEDLINE Pub-Med database (articles published or accepted for publication from December 2002 to December 2007) as well as references from full-length articles, and images in cardiology, on the following items: ampulla's disease, apical ballooning, broken heart syndrome, stress-induced cardiomyopathy, Takotsubo or Takotsubo-like cardiomyopathy (disease, syndrome), and left ventricular thrombus (thrombi, thrombosis).

By searching for these

Demographic and clinical findings

The main characteristics of the 14 selected studies (15 patients) are summarized in Table 1. Overall, 6 reports were from Europe (Germany, Italy and Portugal), three from Japan, three from USA (Illinois, Washington, New York), and two from Mexico.

Each study was a single-case description, with the exception of that by Grabosky et al. [9], in which two patients with cerebral embolism (but just one with indubitable LVTF) were reported, and that by Santos et al. [16], which included 5 patients, but

General aspects of the Takotsubo-like syndrome

Takotsubo-like syndrome is a recent diagnostic entity with typical characteristics, that most frequently affects women over 60 years of age. Although initially described in Japanese populations [20], [21] it has been even reported in Caucasian patients all over the world.

The reasons of such common occurrence in post-menopausal women are uncertain yet. There is a general agreement with the statement that an exaggerated sympathetic drive is the primary mechanism of the syndrome.

Conclusions

Important findings from this review indicate that 15 cases of LVTF complicating a Takotsubo-like syndrome have been reported until the end of 2007.

Based on historical data and the most recent reviews on this subject, which have encountered 600 cases at least with documented Takotsubo-like phenomenon, a LVTF can occur in about 2.5% of the patients with this syndrome.

Cardioembolic complications, but no fatal outcomes, have been reported in 5 patients (33.3%), in the order of 0.8% of the whole

Acknowledgements

The authors wish to thank Dr. Gianluca Di Bella for giving a contribution to the searching phase of the study.

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