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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Takotsubo cardiomyopathy &#40;TC&#41;&#44; or transient left ventricular apical ballooning syndrome&#44; was first recognized in Japan in 1991&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is characterized by self-limited left ventricular mid and apical akinesia&#44; usually precipitated by profound physical or emotional trauma&#46;<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1&#8211;4</span></a> The natural history of TC appears to be benign&#44; requiring supportive therapy until the ventricular dysfunction has resolved&#44;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;4</span></a> but occasionally it has been identified as a precipitant of serious arrhythmias&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;6&#8211;8</span></a> Ventricular dyskinesia combined with increased sympathetic activation which alters the coagulation cascade may explain the apical thrombus formation sporadically reported in these patients&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> We present a case of TC associated with apical thrombus and complete heart block&#46; To our knowledge this is the first report of an association of these two complications simultaneously in the same patient&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 78-year-old woman with unremarkable cardiac and medical history was admitted to our hospital because of dyspnea&#44; chest discomfort and dizziness lasting for a week&#44; since she had been physically assaulted by her husband&#46; On physical examination&#44; she was hemodynamically stable and rales were detected in both lungs&#46; The ECG showed complete heart block with wide QRS complexes &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">A transthoracic echocardiogram revealed severe left ventricular &#40;LV&#41; systolic dysfunction with akinesia of the mid-apical segments and hyperkinesis of the basal segments&#46; Assuming a possible previous infarction with post-infarction angina and severe conduction abnormalities&#44; cardiac catheterization was performed and temporary transvenous pacing was instituted&#46; The coronary angiography excluded significant coronary vascular disease&#58; 40&#37; stenosis of the mild left anterior descending artery &#40;LAD&#41; and 50&#37; of the distal circumflex coronary artery &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; The left ventriculography demonstrated typical &#8220;apical ballooning&#8221; and an apical thrombus &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#44; <a class="elsevierStyleCrossRef" href="#sec0030">video 1</a>&#41;&#46; Contrast echocardiography confirmed the presence of apical thrombus and hypocoagulation therapy was initiated &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">The patient&#39;s clinical evolution was favorable&#44; however the LV dysfunction&#44; wall motion abnormalities and AV conduction abnormalities did not improve significantly during the week after admission&#46; Troponin level was maximum at admission &#40;0&#46;79<span class="elsevierStyleHsp" style=""></span>ng&#47;ml&#41;&#46; Due to the lack of LV function improvement a temporary coronary occlusion could not be ruled out as the cause of apical ballooning&#46; To better clarify the diagnosis cardiac magnetic resonance imaging was performed&#44; almost two weeks after admission&#44; and showed global &#40;ejection fraction&#58; 50&#37;&#41; and regional &#40;hypokinesis of the 17th segment&#44; lateral and inferior apical segments&#41; improvement of LV function&#46; There was no apical thrombus or delayed enhancement&#44; consistent with the diagnosis of TC &#40;<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>&#41;&#46;</p><elsevierMultimedia ident="fig0020"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">The echocardiography performed at this time confirmed the resolution of LV systolic function and wall-motion abnormalities&#46; However&#44; the complete AV block persisted and&#44; consequently&#44; a dual-chamber pacemaker was implanted &#40;<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>&#41;&#46; Pacemaker check at one year identified persistent complete heart block but the patient was asymptomatic&#46;</p><elsevierMultimedia ident="fig0025"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">This case demonstrates that complete AV block associated with takotsubo cardiomyopathy may persist after improvement of left ventricular wall motion&#44; and pacemaker implantation may be needed&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">The physiopathology of TC remains unclear&#44; as does the involvement of the conduction system&#46; It is still not known if in these cases the conduction system is primarily involved or if it suffers the consequence of an acutely distorted cardiac structure&#46; It seems that the remodeling of the ventricle after the acute TC phase recovers within weeks&#44; while the conduction system may take years to recover&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6&#8211;8</span></a> Further follow-up of this patient will help determine whether the conduction disorder is permanent or will resolve over time&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Authorship</span><p id="par0055" class="elsevierStylePara elsevierViewall">Ana Sofia Correia and Nuno Moreno contributed equally to the paper&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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Vol. 31. Issue 7 - 8.
Pages 513-516 (July - August 2012)
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Vol. 31. Issue 7 - 8.
Pages 513-516 (July - August 2012)
Case report
Open Access
Cardiac thrombus and conduction disorder in takotsubo cardiomyopathy
Miocardiopatia de takotsubo complicada com trombo apical e alterações da condução
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Ana Sofia Correiaa,
Corresponding author
sofiakorreia@gmail.com

Corresponding author.
, Nuno Morenob, Alexandra Gonçalvesa, Vítor Araújoa, Teresa Pinhoa, Rui André Rodriguesa, Filipe Macedoa, Maria Júlia Maciela
a Serviço de Cardiologia, Hospital de São João, E.P.E., Porto, Portugal
b Serviço de Cardiologia, Hospital Padre Américo, Vale do Sousa (Centro Hospitalar Tâmega e Sousa, E.P.E.), Penafiel, Portugal
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Abstract

Takotsubo cardiomyopathy is a reversible form of left ventricular dysfunction with an apparently benign natural history after left ventricular recovery. Rarely there are complications such as arrhythmias and apical thrombus. We describe a case of takotsubo cardiomyopathy complicated with apical thrombus and persistent complete atrioventricular block after improvement of left ventricular wall motion.

Keywords:
Takotsubo cardiomyopathy
Complete heart block
Apical thrombus
Resumo

A miocardiopatia de takotsubo constitui uma forma transitória e aparentemente benigna de disfunção ventricular esquerda. Raramente cursa com complicações como arritmias e trombos apicais. Descrevemos um caso de miocardiopatia de takotsubo complicada com trombo apical e bloqueio aurículo-ventricular completo persistente após a normalização da contractilidade do ventrículo esquerdo.

Palavras-chave:
Miocardiopatia de takotsubo
Bloqueio aurículo-ventricular completo
Trombo apical
Full Text
Introduction

Takotsubo cardiomyopathy (TC), or transient left ventricular apical ballooning syndrome, was first recognized in Japan in 1991.1 It is characterized by self-limited left ventricular mid and apical akinesia, usually precipitated by profound physical or emotional trauma.1–4 The natural history of TC appears to be benign, requiring supportive therapy until the ventricular dysfunction has resolved,2,4 but occasionally it has been identified as a precipitant of serious arrhythmias.2,6–8 Ventricular dyskinesia combined with increased sympathetic activation which alters the coagulation cascade may explain the apical thrombus formation sporadically reported in these patients.5 We present a case of TC associated with apical thrombus and complete heart block. To our knowledge this is the first report of an association of these two complications simultaneously in the same patient.

Case report

A 78-year-old woman with unremarkable cardiac and medical history was admitted to our hospital because of dyspnea, chest discomfort and dizziness lasting for a week, since she had been physically assaulted by her husband. On physical examination, she was hemodynamically stable and rales were detected in both lungs. The ECG showed complete heart block with wide QRS complexes (Figure 1).

Figure 1.

Electrocardiography at presentation. Complete heart block with wide QRS escape rhythm (left bundle branch block aberration, 59bpm).

(0.3MB).

A transthoracic echocardiogram revealed severe left ventricular (LV) systolic dysfunction with akinesia of the mid-apical segments and hyperkinesis of the basal segments. Assuming a possible previous infarction with post-infarction angina and severe conduction abnormalities, cardiac catheterization was performed and temporary transvenous pacing was instituted. The coronary angiography excluded significant coronary vascular disease: 40% stenosis of the mild left anterior descending artery (LAD) and 50% of the distal circumflex coronary artery (Figure 2). The left ventriculography demonstrated typical “apical ballooning” and an apical thrombus (Figure 2, video 1). Contrast echocardiography confirmed the presence of apical thrombus and hypocoagulation therapy was initiated (Figure 3).

Figure 2.

Results of cardiac catheterization. Left ventriculography at end-systole (A) and end-diastole (B) demonstrating typical apical ballooning and double outline apex suggestive of apical thrombus. Results of selective coronary angiography of the left main coronary artery (C) showing no significant stenosis.

(0.13MB).
Figure 3.

Contrast echocardiography. Left ventricle at end-systole (A) and end-diastole (B) in apical 4-chamber view, showing typical “apical ballooning” and apical thrombus.

(0.09MB).

The patient's clinical evolution was favorable, however the LV dysfunction, wall motion abnormalities and AV conduction abnormalities did not improve significantly during the week after admission. Troponin level was maximum at admission (0.79ng/ml). Due to the lack of LV function improvement a temporary coronary occlusion could not be ruled out as the cause of apical ballooning. To better clarify the diagnosis cardiac magnetic resonance imaging was performed, almost two weeks after admission, and showed global (ejection fraction: 50%) and regional (hypokinesis of the 17th segment, lateral and inferior apical segments) improvement of LV function. There was no apical thrombus or delayed enhancement, consistent with the diagnosis of TC (Figure 4).

Figure 4.

Cardiac magnetic resonance imaging in 4-chamber view showing absence of apical thrombus or delayed enhancement.

(0.09MB).

The echocardiography performed at this time confirmed the resolution of LV systolic function and wall-motion abnormalities. However, the complete AV block persisted and, consequently, a dual-chamber pacemaker was implanted (Figure 5). Pacemaker check at one year identified persistent complete heart block but the patient was asymptomatic.

Figure 5.

Electrocardiography two weeks after presentation: sustained complete heart block (QRS escape rhythm without left bundle branch block aberration) and evolutionary changes in T-wave morphology with inversion and QTc prolongation.

(0.4MB).
Discussion

This case demonstrates that complete AV block associated with takotsubo cardiomyopathy may persist after improvement of left ventricular wall motion, and pacemaker implantation may be needed.

The physiopathology of TC remains unclear, as does the involvement of the conduction system. It is still not known if in these cases the conduction system is primarily involved or if it suffers the consequence of an acutely distorted cardiac structure. It seems that the remodeling of the ventricle after the acute TC phase recovers within weeks, while the conduction system may take years to recover.6–8 Further follow-up of this patient will help determine whether the conduction disorder is permanent or will resolve over time.

Authorship

Ana Sofia Correia and Nuno Moreno contributed equally to the paper.

Conflicts of interest

The authors have no conflicts of interest to declare.

References
[1]
K. Dote, H. Sato, H. Tateishi, et al.
Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases.
J Cardiol, 21 (1991), pp. 203-214
[2]
M. Gianni, F. Dentali, A.M. Grandi, et al.
Apical ballooning syndrome or takotsubo cardiomyopathy: a systematic review.
Eur Heart J, 27 (2006), pp. 1523-1529
[3]
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The clinical features of takotsubo cardiomyopathy.
QJM, 96 (2003), pp. 563-573
[4]
K.A. Bybee, T. Kara, A. Prasad, et al.
Systematic review: transient left ventricular apical ballooning: a syndrome that mimics ST-segment elevation myocardial infarction.
Ann Intern Med, 141 (2004), pp. 858-865
[5]
M.D. Ricardo Tobar, M.D. Renee Rotzak, M.D. Yoseph Rozenman.
Apical thrombus associated with Takotsubo Cardiomyopathy in a young woman.
Echocardiography, 26 (2009), pp. 575-580
[6]
K. Matsuoka, S. Okubo, E. Fujii, et al.
Evaluation of the arrhythmogenicity of stress-induced “Takotsubo cardiomyopathy” from the time course of the 12-lead surface electrocardiogram.
Am J Cardiol, 92 (2003), pp. 230-233
[7]
M. Inoue, H. Kanaya, T. Matsubara, et al.
Complete atrioventricular block associated with takotsubo cardiomyopathy.
Circ J, 73 (2009), pp. 589-592
[8]
M.A. Nault, A. Baranchuk, C.S. Simpson, et al.
Takotsubo cardiomyopathy: a novel “proarrhythmic” disease.
Anadolu Kardyiol Derg, 7 (2007), pp. 101-103
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