Case ReportSurgical Extirpation of Apical Left Ventricular Thrombus inTakotsubo Cardiomyopathy

Tetsuya Niino and Satoshi Unosawa

Department of Cardiovascular Surgery, National Hospital Organization Disaster Medical Center, Japan

Correspondence should be addressed to Tetsuya Niino; tetsuyan77@gmail.com

Received 16 March 2015; Accepted 19 May 2015

Academic Editor: Christoph Schmitz

Copyright © 2015 T. Niino and S. Unosawa. This is an open access article distributed under the Creative Commons AttributionLicense, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properlycited.

We report a patient with takotsubo cardiomyopathy who underwent surgical resection of apical left ventricular thrombus. A 59-year-old woman was transferred to our hospital in shock with hypothermia and diabetic ketoacidosis. The electrocardiogramshowed ST segment elevation, while echocardiography revealed a reduced ejection fractionwith apical andmidventricular akinesis.Emergency coronary angiography showed normal coronary arteries, so takotsubo cardiomyopathy was diagnosed. Follow-upechocardiography revealed improvement of the ejection fraction. A mobile apical thrombus was also detected. Thrombectomywas performed via a left apical incision and postoperative recovery was uneventful.

1. Introduction

Takotsubo cardiomyopathy, which is also known as transientleft ventricular apical ballooning syndrome, typically occursin persons under severe emotional or physical stress. Takot-subo cardiomyopathy induced by diabetic ketoacidosis hasalso been reported [1].

The prognosis of takotsubo cardiomyopathy is generallyfavorable, with normalization of ventricular wall motionoccurring after a number of weeks, but serious complicationssuch as heart failure, mural thrombus, thromboembolism,ventricular tachycardia, and cardiac rupture have beenreported [2, 3].

We present a case of takotsubo cardiomyopathy compli-cated by left ventricular apical thrombus, in which the throm-bus was successfully removed via apical left ventriculotomy.

2. Case Report

A 59-year-old woman was admitted to our institution withunconsciousness. She had no relevant medical history. Onadmission, she had shock state and systolic blood pressurewas 63mmHg, with dehydration and prominent Kussmaulbreathing. Her temperature was 30.9∘C and her blood glu-cose was 1018mg/dL. Blood gas analysis revealed severe

metabolic acidosis (pH: 6.89) and an increased base excess(−30.4mmol/L). Electrocardiography showed significant STsegment elevation in leads II, III, aVF, and V3–6 (Figure 1).

The patient remained in shock despite treatment of herhypothermia and dehydration. Transthoracic echocardiogra-phy (TTE) demonstrated apical and midventricular akinesisof the left ventricle, with preservation of basal contraction.The ejection fraction (EF) was reduced to less than 25%.Cardiac enzymes were elevated, with creatine kinase being1951 IU/L, creatine kinase-MB being 230 IU/L, and troponinI being 7.94 ng/mL. Coronary angiography was performedimmediately. Because her coronary arteries were normal,takotsubo cardiomyopathy was diagnosed. The patient wastreated with an intra-aortic balloon pump (IABP) for hemo-dynamic support and anticoagulation with heparin. On the2nd day, she was weaned from the IABP. TTE showedimprovement of the EF to 40–50% with no apical thrombus,so heparin was stopped on day 6. New-onset type 1 diabetesmellitus was also diagnosed and she started insulin therapy.

On day 13, TTE revealed normalization of left ventricularwall motion but also showed a mobile round thrombus at theapex of the ventricle (Figure 2). Anticoagulant therapy withwarfarin was started, and we explained the risks and benefitsof surgical treatment and anticoagulant therapy. The patienthas agreed on surgical thrombectomy, which was indicated

Hindawi Publishing CorporationCase Reports in SurgeryVolume 2015, Article ID 387037, 3 pageshttp://dx.doi.org/10.1155/2015/387037

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2 Case Reports in Surgery

I V1

V2

V3

V4

V5

V6

II

III

aVR

aVL

aVF

Figure 1: Electrocardiogram showed significant ST-elevation inleads II, III, aVF, and V3–6.

Figure 2: Echocardiogram showed a mobile mural thrombus in theapex of left ventricle.

because of the embolic potential in a patient recovering fromtakotsubo cardiomyopathy.

Median sternotomy was performed and cardiopul-monary bypasswas established from the superior and inferiorvena cava to the ascending aorta. After cross-clamping theascending aorta, cold crystalloid cardioplegic solution wasadministered antegradely via the aortic root. An incisionwas made at the apex of the left ventricle parallel to the leftanterior descending artery and the thrombus was extirpated.The thrombus was fragile and less than 1 cm in size. Thenthe ventriculotomy was closed with a buttressed mattressstructure and a continuous suture.The aortic cross-clampingtime, cardiopulmonary bypass time, and operating time were29, 67, and 139 minutes, respectively. The present patientwas weaned from cardiopulmonary bypass using low-dosedopamine (2 𝜇g/kg/min), but this was unnecessary at end ofsurgery.

Pathological examination of apical myocardial tissuerevealed interstitial fibrosis and rupture of myocardial fibers,which were findings suggestive of myocarditis. Her postoper-ative course was uneventful and postoperative echocardiog-raphy revealed normal left ventricular function.

3. Discussion

The prognosis of patients with takotsubo cardiomyopathy isgenerally favorable, although death sometimes occurs dueto complications such as heart failure, mural thrombus,thromboembolism, or cardiac rupture [2, 3].

De Gregorio et al. reported intracavitary thrombusin 2.5% of patients with takotsubo cardiomyopathy andembolic complications in 33.3% of those with left ven-tricular thrombosis, including stroke, renal infarction, andpopliteal thrombosis [4]. Accordingly, anticoagulant therapyis recommended for patients with takotsubo cardiomyopathy,but thromboembolism has been reported in some patientsdespite anticoagulation with heparin or warfarin [5]. It hasbeen reported that plasma catecholamine levels are markedlyelevated in patients with takotsubo cardiomyopathy, suggest-ing the possibility of catecholamine-induced platelet activa-tion and aggregation [6–8].

However, takotsubo cardiomyopathy complicated ven-tricular apical rupture due to transmural myocardial necrosiswith hemorrhage has been reported. Therefore, whetheranticoagulant therapy with warfarin should be routinelyperformed in these patients to prevent thrombosis remainscontroversial.

Surgery and anesthesia have been associated with takot-subo cardiomyopathy, and it has been suggested that exces-sive circulating levels of catecholamines due to surgical stressmay induce this cardiomyopathy [9]. Dobutamine stress testhas also possibility of induced takotsubo cardiomyopathy[10].

The thromboembolism occurred in 0 to 20% with leftventricular thrombus in takotsubo cardiomyopathy underanticoagulation therapy [11–13]. Management of left ventric-ular thrombus in patients with takotsubo cardiomyopathy iscontroversial; conservative therapy has the possibility to beeffective and safe if the thrombi are smooth, conform to thecavity shape, and are relatively stable. But the risk of embolismis relatively high when the thrombus is located in the apicalregion and surgical thrombectomy needs to be considered,especially in patients with amobile thrombus [14].There havebeen previous reports about thrombectomy via apical leftventriculotomy or a transmitral approach, although the lattergives a poor view of the target [13, 15]. In our patient, apicalventriculotomy provided good access for thrombectomy.

In conclusion, we found that left apical ventriculotomywas useful to approach an apical thrombus, and surgicalthrombectomy is an option for left apical thrombus inpatients with takotsubo cardiomyopathy.

Conflict of Interests

The authors have no conflict of interests.

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