Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry

Abstract

BackgroundLeft ventricular (LV) thrombi during Takotsubo syndrome represent a potential complication and can be associated with cerebrovascular embolic events. The aim of this study was to evaluate the exact incidence, predictors, and management strategies of LV thrombi in patients with Takotsubo syndrome.Methods and ResultsWe enrolled 541 consecutive patients in a multicenter international registry. Clinical features and echocardiographic data at admission, during hospitalization, and after 3 months were evaluated. Survival rates for long‐term follow‐up (mean 984±908 days) were recorded. Twelve Takotsubo syndrome patients (2.2%) developed LV thrombi (all female presenting with apical ballooning pattern). All patients with LV thrombi were treated with oral anticoagulation therapy; however, 2 (17%) had a stroke before treatment initiation. These patients were characterized by a higher prevalence of ST‐elevation (56% versus 16%; P<0.001) and higher troponin I levels (10.8±18.3 ng/mL versus 3.5±4.3 ng/mL; P=0.001) as compared with those without LV thrombi. At multivariate analysis including age, sex, LV ejection fraction, ST‐elevation at admission, and apical ballooning pattern, troponin I level >10 ng/mL was the only predictor for LV thrombosis (hazard ratio 6.6, confidence interval, 1.01–40.0; P=0.04). After 3 months all LV thrombi disappeared. Oral anticoagulation therapy was interrupted in all patients except 1. At long‐term follow‐up, the survival rate was not different between patients with and without LV thrombi (84% versus 85%; P=0.99).Conclusions LV thrombi have a relatively low incidence among patients with Takotsubo syndrome and were detected in female patients with apical ballooning pattern and increased troponin levels. Oral anticoagulation therapy for 3 months seems reasonable in these high‐risk patients.

Thrombo‐embolic complications in takotsubo syndrome: Review and demonstration of an illustrative case

“…All 15 patients with LVT reported by de Gregorio et al had apical or mid‐apical ballooning pattern of TS. Similarly, all 12 patients with LVT reported by Santoro et al had apical ballooning pattern. LVT has also been reported (but rarely) in apical sparing patterns of TS where the thrombus may occur adjacent to the papillary cardiac muscles .…”

“…In most of the cases, the LVT occurs in the apical or mid‐apical patterns of TS, and at the apical region of the left ventricle where low blood flow is a contributing factor for LVT formation . All 15 patients with LVT reported by de Gregorio et al had apical or mid‐apical ballooning pattern of TS.…”

“…A protruding thrombus is projected into the left ventricular cavity; it is usually spherical and may be mobile where some parts of the thrombus moves independently of the underlying myocardium. The thrombus is mural in about 40% and protruding in about 60% of patients with LVT in TS …”

“…It is sensible to treat even cases with extensive mid‐apical ballooning, where the risk of thrombo‐embolism is substantial, as a prophylactic measure. In a recent study, increased troponin levels (troponin I level >10 ng/mL) and apical ballooning were strongly associated with the occurrence of LVT and anticoagulation should be considered in such cases as a prophylactic treatment. The anticoagulation should be continued for 2 to 3 months or at least until the LVWMA and LVT have resolved.…”

“…LVT has been reported in 1% to 8% in patients with TS . Thrombo‐embolism has been reported in 2% to 14% of patients with TS in general . Cardio‐embolic events have occurred in 17% to 33% in those with LVT in TS .…”