Intraventricular Thrombus Formation and Embolism in Takotsubo Syndrome
Authors: Ding Katharina J. , Cammann Victoria L. , Szawan Konrad A. , Stähli Barbara E. , Wischnewsky Manfred , Di Vece Davide , Citro Rodolfo , Jaguszewski Milosz , Seifert Burkhardt , Sarcon Annahita , Knorr Maike , Heiner Susanne , Gili Sebastiano , D’Ascenzo Fabrizio , Neuhaus Michael , Napp L. Christian , Franke Jennifer , Noutsias Michel , Burgdorf Christof , Koenig Wolfgang , Kherad Behrouz , Rajan Lawrence , Michels Guido , Pfister Roman , Cuneo Alessandro , Jacobshagen Claudius , Karakas Mahir , Pott Alexander , Meyer Philippe , Arroja Jose D. , Banning Adrian , Cuculi Florim , Kobza Richard , Fischer Thomas A. , Vasankari Tuija , Airaksinen K.E. Juhani , Paolini Carla , Bilato Claudio , Carrilho-Ferreira Pedro , Opolski Grzegorz , Dworakowski Rafal , MacCarthy Philip , Kaiser Christoph , Osswald Stefan , Galiuto Leonarda , Dichtl Wolfgang , Chan Christina , Bridgman Paul , Delmas Clément , Lairez Olivier , El-Battrawy Ibrahim , Akin Ibrahim , Gilyarova Ekaterina , Shilova Alexandra , Gilyarov Mikhail , Kozel Martin , Tousek Petr , Widimský Petr , Winchester David E. , Galuszka Jan , Ukena Christian , Horowitz John D. , Di Mario Carlo , Prasad Abhiram , Rihal Charanjit S. , Pinto Fausto J. , Crea Filippo , Borggrefe Martin , Braun-Dullaeus Ruediger C. , Rottbauer Wolfgang , Bauersachs Johann , Katus Hugo A. , Hasenfuß Gerd , Tschöpe Carsten , Pieske Burkert M. , Thiele Holger , Schunkert Heribert , Böhm Michael , Felix Stephan B. , Münzel Thomas , Bax Jeroen J. , Lüscher Thomas F. , Ruschitzka Frank , Ghadri Jelena R. , Bossone Eduardo , Templin Christian 
Published: November 2019

Objective:
Takotsubo syndrome (TTS) is characterized by acute left ventricular dysfunction, which can contribute to intraventricular thrombus and embolism. Still, prevalence and clinical impact of thrombus formation and embolic events on outcome of TTS patients remain unclear. This study aimed to investigate clinical features and outcomes of patients with and without intraventricular thrombus or embolism. Additionally, factors associated with thrombus formation or embolism, as well as predictors for mortality, were identified.

Approach and Results:

TTS patients enrolled in the International Takotsubo Registry at 28 centers in Australia, Europe, and the United States were dichotomized according to the occurrence/absence of intraventricular thrombus or embolism. Patients with intraventricular thrombus or embolism were defined as the ThrombEmb group. Of 1676 TTS patients, 56 (3.3%) patients developed intraventricular thrombus and/or embolism following TTS diagnosis (median time interval, 2.0 days [range, 0–38 days]). Patients in the ThrombEmb group had a different clinical profile including lower left ventricular ejection fraction, higher prevalence of the apical type, elevated levels of troponin and inflammatory markers, and higher prevalence of vascular disease. In a Firth bias-reduced penalized-likelihood logistic regression model apical type, left ventricular ejection fraction ≤30%, previous vascular disease, and a white blood cell count on admission >10×10
3
cells/μL emerged as independent predictors for thrombus formation or embolism.

Conclusions:
Intraventricular thrombus or embolism occur in 3.3% of patients in the acute phase of TTS. A simple risk score including clinical parameters associated with intraventricular thrombus formation or embolism identifies patients at increased risk.

Clinical Trial Registration:

URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT01947621.