Case report
Cardiac thrombus and conduction disorder in takotsubo cardiomyopathy
Miocardiopatia de takotsubo complicada com trombo apical e alterações da condução
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de Cardiologia, Hospital de São João, E.P.E., Porto, Portugal" "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Serviço de Cardiologia, Hospital Padre Américo, Vale do Sousa (Centro Hospitalar Tâmega e Sousa, E.P.E.), Penafiel, Portugal" "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Miocardiopatia de takotsubo complicada com trombo apical e alterações da condução" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 978 "Ancho" => 3000 "Tamanyo" => 256630 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Takotsubo cardiomyopathy (TC), or transient left ventricular apical ballooning syndrome, was first recognized in Japan in 1991.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> It is characterized by self-limited left ventricular mid and apical akinesia, usually precipitated by profound physical or emotional trauma.<a class="elsevierStyleCrossRefs" href="#bib0005"><span class="elsevierStyleSup">1–4</span></a> The natural history of TC appears to be benign, requiring supportive therapy until the ventricular dysfunction has resolved,<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,4</span></a> but occasionally it has been identified as a precipitant of serious arrhythmias.<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2,6–8</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.<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. To our knowledge this is the first report of an association of these two complications simultaneously in the same patient.</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, 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 (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">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 (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>). The left ventriculography demonstrated typical “apical ballooning” and an apical thrombus (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>, <a class="elsevierStyleCrossRef" href="#sec0030">video 1</a>). Contrast echocardiography confirmed the presence of apical thrombus and hypocoagulation therapy was initiated (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>).</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">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 (0.79<span class="elsevierStyleHsp" style=""></span>ng/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 (<a class="elsevierStyleCrossRef" href="#fig0020">Figure 4</a>).</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. However, the complete AV block persisted and, consequently, a dual-chamber pacemaker was implanted (<a class="elsevierStyleCrossRef" href="#fig0025">Figure 5</a>). Pacemaker check at one year identified persistent complete heart block but the patient was asymptomatic.</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, and pacemaker implantation may be needed.</p><p id="par0035" class="elsevierStylePara elsevierViewall">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.<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">6–8</span></a> Further follow-up of this patient will help determine whether the conduction disorder is permanent or will resolve over time.</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.</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.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:2 [ "identificador" => "xres250406" "titulo" => "Abstract" ] 1 => array:2 [ "identificador" => "xpalclavsec237973" "titulo" => "Keywords" ] 2 => array:2 [ "identificador" => "xres250405" "titulo" => "Resumo" ] 3 => array:2 [ "identificador" => "xpalclavsec237974" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Case report" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Authorship" ] 8 => array:2 [ "identificador" => "sec0020" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2011-09-18" "fechaAceptado" => "2011-11-07" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec237973" "palabras" => array:3 [ 0 => "Takotsubo cardiomyopathy" 1 => "Complete heart block" 2 => "Apical thrombus" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec237974" "palabras" => array:3 [ 0 => "Miocardiopatia de takotsubo" 1 => "Bloqueio aurículo-ventricular completo" 2 => "Trombo apical" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0050" class="elsevierStylePara elsevierViewall"><elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0030" ] ] ] ] "multimedia" => array:6 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 950 "Ancho" => 3325 "Tamanyo" => 752494 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Electrocardiography at presentation. Complete heart block with wide QRS escape rhythm (left bundle branch block aberration, 59<span class="elsevierStyleHsp" style=""></span>bpm).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 978 "Ancho" => 3000 "Tamanyo" => 256630 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 958 "Ancho" => 2500 "Tamanyo" => 121036 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Contrast echocardiography. Left ventricle at end-systole (A) and end-diastole (B) in apical 4-chamber view, showing typical “apical ballooning” and apical thrombus.</p>" ] ] 3 => array:7 [ "identificador" => "fig0020" "etiqueta" => "Figure 4" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr4.jpeg" "Alto" => 1188 "Ancho" => 1667 "Tamanyo" => 137221 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Cardiac magnetic resonance imaging in 4-chamber view showing absence of apical thrombus or delayed enhancement.</p>" ] ] 4 => array:7 [ "identificador" => "fig0025" "etiqueta" => "Figure 5" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr5.jpeg" "Alto" => 1488 "Ancho" => 3242 "Tamanyo" => 1016946 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">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.</p>" ] ] 5 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:3 [ "fichero" => "mmc1.mpg" "ficheroTamanyo" => 1540096 "Video" => array:2 [ "flv" => array:5 [ "fichero" => "mmc1.flv" "poster" => "mmc1.jpg" "tiempo" => 0 "alto" => 0 "ancho" => 0 ] "mp4" => array:2 [ "fichero" => "mmc1.m4v" "poster" => "mmc1.jpg" ] ] ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Myocardial stunning due to simultaneous multivessel coronary spasms: a review of 5 cases" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "K. 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| Ano/Mês | Html | Total | |
|---|---|---|---|
| 2024 Novembro | 10 | 4 | 14 |
| 2024 Outubro | 37 | 33 | 70 |
| 2024 Setembro | 71 | 25 | 96 |
| 2024 Agosto | 66 | 26 | 92 |
| 2024 Julho | 55 | 31 | 86 |
| 2024 Junho | 39 | 25 | 64 |
| 2024 Maio | 46 | 19 | 65 |
| 2024 Abril | 42 | 29 | 71 |
| 2024 Maro | 59 | 19 | 78 |
| 2024 Fevereiro | 42 | 20 | 62 |
| 2024 Janeiro | 30 | 25 | 55 |
| 2023 Dezembro | 24 | 20 | 44 |
| 2023 Novembro | 35 | 25 | 60 |
| 2023 Outubro | 22 | 18 | 40 |
| 2023 Setembro | 31 | 16 | 47 |
| 2023 Agosto | 34 | 22 | 56 |
| 2023 Julho | 40 | 6 | 46 |
| 2023 Junho | 28 | 13 | 41 |
| 2023 Maio | 52 | 29 | 81 |
| 2023 Abril | 31 | 2 | 33 |
| 2023 Maro | 39 | 20 | 59 |
| 2023 Fevereiro | 43 | 24 | 67 |
| 2023 Janeiro | 24 | 10 | 34 |
| 2022 Dezembro | 45 | 19 | 64 |
| 2022 Novembro | 48 | 20 | 68 |
| 2022 Outubro | 51 | 21 | 72 |
| 2022 Setembro | 34 | 24 | 58 |
| 2022 Agosto | 36 | 25 | 61 |
| 2022 Julho | 27 | 40 | 67 |
| 2022 Junho | 29 | 21 | 50 |
| 2022 Maio | 24 | 32 | 56 |
| 2022 Abril | 26 | 28 | 54 |
| 2022 Maro | 33 | 38 | 71 |
| 2022 Fevereiro | 17 | 17 | 34 |
| 2022 Janeiro | 22 | 18 | 40 |
| 2021 Dezembro | 27 | 32 | 59 |
| 2021 Novembro | 42 | 37 | 79 |
| 2021 Outubro | 43 | 47 | 90 |
| 2021 Setembro | 22 | 24 | 46 |
| 2021 Agosto | 37 | 28 | 65 |
| 2021 Julho | 21 | 22 | 43 |
| 2021 Junho | 35 | 13 | 48 |
| 2021 Maio | 29 | 28 | 57 |
| 2021 Abril | 63 | 31 | 94 |
| 2021 Maro | 57 | 22 | 79 |
| 2021 Fevereiro | 43 | 17 | 60 |
| 2021 Janeiro | 47 | 9 | 56 |
| 2020 Dezembro | 36 | 9 | 45 |
| 2020 Novembro | 37 | 6 | 43 |
| 2020 Outubro | 36 | 9 | 45 |
| 2020 Setembro | 42 | 17 | 59 |
| 2020 Agosto | 27 | 12 | 39 |
| 2020 Julho | 46 | 9 | 55 |
| 2020 Junho | 59 | 7 | 66 |
| 2020 Maio | 40 | 1 | 41 |
| 2020 Abril | 41 | 8 | 49 |
| 2020 Maro | 50 | 12 | 62 |
| 2020 Fevereiro | 92 | 30 | 122 |
| 2020 Janeiro | 28 | 8 | 36 |
| 2019 Dezembro | 46 | 6 | 52 |
| 2019 Novembro | 27 | 6 | 33 |
| 2019 Outubro | 30 | 3 | 33 |
| 2019 Setembro | 65 | 10 | 75 |
| 2019 Agosto | 30 | 6 | 36 |
| 2019 Julho | 40 | 9 | 49 |
| 2019 Junho | 52 | 9 | 61 |
| 2019 Maio | 36 | 11 | 47 |
| 2019 Abril | 34 | 13 | 47 |
| 2019 Maro | 43 | 11 | 54 |
| 2019 Fevereiro | 50 | 11 | 61 |
| 2019 Janeiro | 29 | 3 | 32 |
| 2018 Dezembro | 46 | 13 | 59 |
| 2018 Novembro | 108 | 8 | 116 |
| 2018 Outubro | 271 | 18 | 289 |
| 2018 Setembro | 42 | 14 | 56 |
| 2018 Agosto | 43 | 23 | 66 |
| 2018 Julho | 38 | 7 | 45 |
| 2018 Junho | 51 | 7 | 58 |
| 2018 Maio | 58 | 13 | 71 |
| 2018 Abril | 56 | 10 | 66 |
| 2018 Maro | 76 | 6 | 82 |
| 2018 Fevereiro | 43 | 6 | 49 |
| 2018 Janeiro | 31 | 3 | 34 |
| 2017 Dezembro | 56 | 13 | 69 |
| 2017 Novembro | 57 | 10 | 67 |
| 2017 Outubro | 42 | 10 | 52 |
| 2017 Setembro | 56 | 11 | 67 |
| 2017 Agosto | 52 | 14 | 66 |
| 2017 Julho | 50 | 14 | 64 |
| 2017 Junho | 48 | 18 | 66 |
| 2017 Maio | 51 | 12 | 63 |
| 2017 Abril | 39 | 12 | 51 |
| 2017 Maro | 41 | 4 | 45 |
| 2017 Fevereiro | 31 | 7 | 38 |
| 2017 Janeiro | 36 | 3 | 39 |
| 2016 Dezembro | 44 | 22 | 66 |
| 2016 Novembro | 47 | 19 | 66 |
| 2016 Outubro | 44 | 27 | 71 |
| 2016 Setembro | 23 | 9 | 32 |
| 2016 Agosto | 23 | 7 | 30 |
| 2016 Julho | 12 | 10 | 22 |
| 2016 Junho | 4 | 0 | 4 |
| 2016 Maio | 26 | 8 | 34 |
| 2016 Abril | 29 | 5 | 34 |
| 2016 Maro | 62 | 21 | 83 |
| 2016 Fevereiro | 68 | 27 | 95 |
| 2016 Janeiro | 71 | 15 | 86 |
| 2015 Dezembro | 75 | 16 | 91 |
| 2015 Novembro | 64 | 15 | 79 |
| 2015 Outubro | 76 | 19 | 95 |
| 2015 Setembro | 86 | 13 | 99 |
| 2015 Agosto | 70 | 10 | 80 |
| 2015 Julho | 62 | 9 | 71 |
| 2015 Junho | 39 | 6 | 45 |
| 2015 Maio | 64 | 14 | 78 |
| 2015 Abril | 60 | 12 | 72 |
| 2015 Maro | 60 | 6 | 66 |
| 2015 Fevereiro | 46 | 5 | 51 |
| 2015 Janeiro | 53 | 12 | 65 |
| 2014 Dezembro | 47 | 13 | 60 |
| 2014 Novembro | 59 | 6 | 65 |
| 2014 Outubro | 63 | 12 | 75 |
| 2014 Setembro | 48 | 10 | 58 |
| 2014 Agosto | 56 | 12 | 68 |
| 2014 Julho | 47 | 9 | 56 |
| 2014 Junho | 50 | 9 | 59 |
| 2014 Maio | 61 | 7 | 68 |
| 2014 Abril | 56 | 8 | 64 |
| 2014 Maro | 87 | 17 | 104 |
| 2014 Fevereiro | 87 | 22 | 109 |
| 2014 Janeiro | 84 | 18 | 102 |
| 2013 Dezembro | 60 | 15 | 75 |
| 2013 Novembro | 66 | 15 | 81 |
| 2013 Outubro | 65 | 15 | 80 |
| 2013 Setembro | 56 | 22 | 78 |
| 2013 Agosto | 79 | 29 | 108 |
| 2013 Julho | 121 | 24 | 145 |
| 2013 Junho | 70 | 33 | 103 |
| 2013 Maio | 81 | 22 | 103 |
| 2013 Abril | 103 | 37 | 140 |
| 2013 Maro | 82 | 27 | 109 |
| 2013 Fevereiro | 79 | 25 | 104 |
| 2013 Janeiro | 98 | 37 | 135 |
| 2012 Dezembro | 73 | 34 | 107 |
| 2012 Novembro | 55 | 41 | 96 |
| 2012 Outubro | 48 | 18 | 66 |
| 2012 Setembro | 33 | 14 | 47 |
| 2012 Janeiro | 81 | 0 | 81 |
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