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