Thromboembolic Complications In Takotsubo Syndrome During COVID-19 Outbreak. A A Review With Case Report

Abstract

COVID-19 outbreak, which started in Wuhan, China and spread rapidly all over the world, has become the most important cause of the emotional distress for susceptible people. Because the people also remained in fear and anxiety during the period when the elderly population in the whole country was desperate due to the COVID-19 outbreak and was asked to stay at home in fear of death. In addition, the fact that the patients were hospitalized together with COVID-19 patients caused his psychological distress to be experienced even more. Takotsubo Syndrome (TTS) is known as a distress-induced transient left ventricular dysfunction. In our patient with TTS, it was found that a new apical thrombus, which was not seen in the left ventricle, was seen in previous echo and CT exams, and that it was a source of thromboemboli, by stress triggering neurocardiac reactions. While under the medical treatment of viral pneumonia, under the Coronavirus transmission measures, thrombus in the LV was removed by being taken to the emergency open heart surgery. Our case is the first patient in the literature where a new thrombus developed in the LV and splenic infarction in TTS triggered by the pandemic. In this article; We have presented the experience of TTS triggered by pandemic, etiopathogenesis of left ventricular thrombus, open heart surgery indications when COVID-19 is suspected, coronavirus transmission measures in the surgical approach, the postoperative treatment and literature is reviewed.

Keywords

• Splenic artery occlusion,
• takotsubo syndrome,
• left ventricular motile giant thrombus,
• thromboembolism
• Covid-19

References

1. Akar, A.R., Ertugay, S., Kervan, Ü., İnan, M.B., Sargın, M., Engin, Ç., Özatik, M.A., 2020. Turkish Society of Cardiovascular Surgery (TSCVS) Proposal for use of ECMO in respiratory and circulatory failure in COVID-19 pandemic era. Türk Göğüs Kalp Damar Cerrahisi Derg.28:229-235.
2. Akashi, Y.J., Musha, H., Nakazawa, K., Miyake, F., 2004 Plasma brain natriuretic peptide in takotsubo cardiomyopathy. QJM. 97:599-607.
3. Akay, T., 2020. Perioperative planning in the COVID-19 pandemic: Vascular issues. Türk Göğüs Kalp Damar Cerrahisi Derg. 28:244-246.
4. Basile, C., Combe, C., Pizzarelli, F., Covic, A., Davenport, A., Kanbay, M., et al., 2020. Recommendations for the prevention, mitigation and containment of the emerging SARS-CoV-2 (COVID-19) pandemic in haemodialysis centres. Nephrol Dial Transplant. 35:737-741.
5. Bolcal, C., Kadan, M., Kubat, E., Erol, G., Doğancı, S., 2019. Surgical treatment of a left ventricular apical thrombus via robotic surgery. J Card Surg. 34:216-218.
6. Brooks, S.K., Webster, R.K., Smith, L.E., Woodland, L., Wessely, S., Greenberg, N., Rubin, G.J., 2020. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet 395:912-920.
7. Cecchi, E., Parodi, G., Giglioli, C., Passantino, S., Bandinelli, B., Liotta, A.A., et al., 2013. Stress-induced hyperviscosity in the pathophysiology of takotsubo cardiomyopathy. Am J Cardiol. 111:1523-1529.
8. Chadha, S., 2020. COVID-19 pandemic' anxiety-induced Takotsubo cardiomyopathy. QJM. 113:488-90.

9. Dawson, D.K., 2018. Acute stress-induced (takotsubo) cardiomyopathy. Heart. 104:96-102.
10. de Gregorio, C., Grimaldi, P., Lentini, C., 2008. Left ventricular thrombus formation and cardioembolic complications in patients with Takotsubo-like syndrome: a systematic review. Int J Cardiol. 131:18-24.
11. El Mahmoud, R., Mansencal, N., Pilliére, R., Leyer, F., Abbou, N., Michaud, P., et al., 2008. Prevalence and characteristics of left ventricular outflow tract obstruction in Tako-Tsubo syndrome. Am Heart J. 156:543-548.
12. Fan, B.E., Chia, Y.W., Sum, C.L.L., Kuperan, P., Chan, S.S.W., Ling, L.M., et al., 2020. Global haemostatic tests in rapid diagnosis and management of COVID-19 associated coagulopathy in acute limb ischaemia. J Thromb Thrombolysis. 30:1-6.
13. Ghadri, J.R., Wittstein, I.S., Prasad, A., Sharkey, S., Dote, K., Akashi, Y.J., et al., 2018. International Expert Consensus Document on Takotsubo Syndrome (Part I): Clinical Characteristics, Diagnostic Criteria, and Pathophysiology. Eur Heart J. 39:2032-2046.
14. Günaydın, S., 2020. Perioperative planning in the COVID-19 pandemic: Cardiovascular perfusion and device-related issues. Turk Gogus Kalp Damar Cerrahisi Derg 28:247-249.
15. Haghi, D., Papavassiliu, T., Heggemann, F., Kaden, J.J., Borggrefe, M., Suselbeck, T., 2008. Incidence and clinical significance of left ventricular thrombus in tako-tsubo cardiomyopathy assessed with echocardiography. QJM. 101:381-386.
16. Herath, H.M.M.T.B., Pahalagamage, S.P., Lindsay, L.C., Vinothan, S., Withanawasam, S., Senarathne, V., Withana, M., 2017. Takotsubo cardiomyopathy complicated with apical thrombus formation on first day of the illness: a case report and literature review. BMC Cardiovasc Disord. 17:176.
17. Hombach, V., Merkle, N., Kestler, H.A., Torzewski, J., Kochs, M., Marx, N., et al., 2008. Characterization of patients with acute chest pain using cardiac magnetic resonance imaging. Clin Res Cardiol. 97:760-767.
18. Icli, A., Akilli, H., Kayrak, M., Aribas, A., Ozdemir, K., 2016. Short-term warfarin treatment for apical thrombus in a patient with Takotsubo cardiomyopathy. Cardiovasc J Afr. 27:e12-14.
19. Jensen, J.B., Malouf, J.F., 2006. Takotsubo cardiomyopathy following cholecystectomy: a poorly recognized cause of acute reversible left ventricular dysfunction. Int J Cardiol. 106:390-391.
20. Jeon, U., Park, S., Park, S., Lee, E.Y., Gil, H.W., 2018. Clinical characteristics of stress cardiomyopathy in patients with acute poisoning. Sci Rep. 8:223.
21. Kahya Eren, N., Emren, S.V., Duygu, H., Kocabaş, U., 2013. Left ventricular thrombus formation in a patient with normal ejection fraction]. Turk Kardiyol Dern Ars. 41:625-628.
22. Konstantinos, T., Andreas, S.T., Dimitrios, T., Eleftherios, S., Christoph, M., Charalampos, T., et al., 2020. COVID-19 Related Stress Exacerbates Common Physical and Mental Pathologies and Affects Treatment (Review). Exp Ther Med. 20:159-162.
23. Kurisu, S., Inoue I., Kawagoe T., Ishihara M., Shimatani Y., Nakamura S., et al., 2004. Time course of electrocardiographic changes in patients with tako-tsubo syndrome: comparison with acute myocardial infarction with minimal enzymatic release. Circ J. 68:77-81.
24. Kurisu, S., Inoue, I., Kawagoe, T., Ishihara, M., Shimatani, Y., Nakama, Y., et al., 2011. Incidence and treatment of left ventricular apical thrombosis in Tako-tsubo cardiomyopathy. Int J Cardiol. 146:e58-60.
25. Lee, J.M., Park, J.J., Jung, H.W., Cho, Y.S., Oh, I.Y., Yoon, C.H., et al., 2013. Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents. J Atheroscler Thromb. 20:73-93.
26. Lodigiani, C., Iapichino, G., Carenzo, L., Cecconi, M., Ferrazzi, P., Sebastian, T., et al., 2020. Humanitas COVID-19 Task Force. Venous and arterial thromboembolic complications in COVID-19 patients admitted to an academic hospital in Milan, Italy. Thromb Res. 191:9-14.
27. Lyon, A.R., Rees, P.S., Prasad, S., Poole,-Wilson, P.A., Harding, S.E., 2008. Stress (Takotsubo) cardiomyopathy--a novel pathophysiological hypothesis to explain catecholamine-induced acute myocardial stunning. Nat Clin Pract Cardiovasc Med. 5:22-29.
28. Mallory, R., Balcezak, T., 1999. Treatment of mobile left ventricular thrombus with low-molecular-weight heparin. N Engl J Med. 341:1082-1083.
29. Mano, Y., Koide, K., Sukegawa, H., Kodaira, M., Ohki, T., 2016. Successful resolution of a left ventricular thrombus with apixaban treatment following acute myocardial infarction. Heart Vessels. 31:118-123.
30. Martin, E.A., Prasad, A., Rihal, C.S., Lerman, L.O., Lerman, A., 2010. Endothelial function and vascular response to mental stress are impaired in patients with apical ballooning syndrome. J Am Coll Cardiol. 56:1840-1846.
31. Meurin, P., Tabet, J.Y., Renaud, N., Weber, H., Grosdemouge, A., Bourmayan, C., Driss, A.B., 2005. Treatment of left ventricular thrombi with a low molecular weight heparin. Int J Cardiol. 98:319-323.
32. Meyer, P., Degrauwe, S., Van Delden, C., Ghadri, J.R., Templin, C., 2020. Typical takotsubo syndrome triggered by SARS-CoV-2 infection. Eur Heart J. 41:1860.
33. Minhas, A.S., Scheel, P., Garibaldi, B., Liu, G., Horton, M., Jennings, M., et al., 2020. Takotsubo Syndrome in the Setting of COVID-19 Infection. JACC Case Rep. 2:1321-1325.
34. Moderato, L., Monello, A., Lazzeroni, D., Binno, S., Giacalone, R., Ferraro, S., et al., 2020. [Takotsubo syndrome during SARS-CoV-2 pneumonia: a possible cardiovascular complication]. G Ital Cardiol (Rome). 21:417-420.
35. Niedeggen, A., Lejczyk, J., Kroner, S., Stortz, C., Reith, S., Janssens, U., 2008. Treatment of intracardiac thrombi with argatroban. Acute Card Care. 10:221-226.
36. Niino, T., Unosawa, S., 2015. Surgical Extirpation of Apical Left Ventricular Thrombus in Takotsubo Cardiomyopathy. Case Rep Surg. 2015:387037.
37. Ohashi, N., Okada, T., Uchida, M., Amioka, M., Fujiwara, M., Kaseda, S., 2015. Effects of Dabigatran on the Resolution of Left Ventricular Thrombus after Acute Myocardial Infarction. Intern Med. 54:1761-1763.
38. Pan, Y., Long, L., Zhang, D., Yuan, T., Cui, S., Yang, P., et al., 2020. Potential False-Negative Nucleic Acid Testing Results for Severe Acute Respiratory Syndrome Coronavirus 2 from Thermal Inactivation of Samples with Low Viral Loads. Clin Chem. 66:794-801.
39. Parodi, G., Del Pace, S., Carrabba, N., Salvadori, C., Memisha, G., Simonetti, I., et al., 2007. Incidence, clinical findings, and outcome of women with left ventricular apical ballooning syndrome. Am J Cardiol. 99:182-185.
40. Peters, M.N., George, P., Irimpen, A.M., 2015. The broken heart syndrome: Takotsubo cardiomyopathy. Trends Cardiovasc Med. 25:351-357.
41. Prasad, A., Lerman, A., Rihal, C.S., 2008. Apical ballooning syndrome (Tako-Tsubo or stress cardiomyopathy): a mimic of acute myocardial infarction. Am Heart J. 155:408-417.
42. Roca, E., Lombardi, C., Campana, M., Vivaldi, O., Bigni, B., Bertozzi, B., Passalacqua, G., 2020. Takotsubo Syndrome Associated with COVID-19. Eur J Case Rep Intern Med. 7:001665.
43. Santoro, F., Tarantino, N., Ieva, R., Musaico, F., Di Biase, M., Brunetti, N.D., 2014. Hereditary hypercoagulable state and Takotsubo cardiomyopathy: a possible link. Int J Cardiol. 174:e108-109.
44. Santoro, F., Tarantino, N., Ferraretti, A., Ieva, R., Musaico, F., Guastafierro, F., et al., 2016. Serum interleukin 6 and 10 levels in Takotsubo cardiomyopathy: Increased admission levels may predict adverse events at follow-up. Atherosclerosis. 254:28-34.
45. Santoro, F., Stiermaier, T., Tarantino, N., De Gennaro, L., Moeller, C., Guastafierro, F., et al., 2017. Left Ventricular Thrombi in Takotsubo Syndrome: Incidence, Predictors, and Management: Results From the GEIST (German Italian Stress Cardiomyopathy) Registry. J Am Heart Assoc. 6:e006990.
46. Sari, I., Davutoğlu, V., Soydinc, S., Sucu, M., Ozer, O., 2008. Fibrinolytic treatment in left ventricular mobile thrombi with low ejection fraction: results and follow-up of seven cases. J Thromb Thrombolysis. 25:293-296.
47. Sasaki, N., Kinugawa, T., Yamawaki, M., Furuse, Y., Shimoyama, M., Ogino, K., et al., 2004. Transient left ventricular apical ballooning in a patient with bicuspid aortic valve created a left ventricular thrombus leading to acute renal infarction. Circ J. 68:1081-1083.
48. Schattner, A., Adi, M., Kitroser, E., Klepfish, A., 2015. Acute Splenic Infarction at an Academic General Hospital Over 10 Years: Presentation, Etiology, and Outcome. Medicine (Baltimore). 94:e1363.
49. Shi, S., Qin, M., Shen, B., Cai, Y., Liu, T., Yang, F., et al., 2020. Association of Cardiac Injury With Mortality in Hospitalized Patients With COVID-19 in Wuhan, China. JAMA Cardiol. 25:e200950.
50. Smeijers, L., Szabó, B.M., Kop, W.J., 2016. Psychological distress and personality factors in takotsubo cardiomyopathy. Neth Heart J. 24:530-537.
51. Suzuki, R., Kudo, T., Kurazumi, H., Takahashi, M., Shirasawa, B., Mikamo, A., Hamano ,K., 2013. Transapical extirpation of a left ventricular thrombus in TTS. J Cardiothorac Surg. 8:135.
52. Tanaka, D., Unai, S., Diehl, J.T., Hirose, H., 2014. Surgical removal of a large mobile left ventricular thrombus via left atriotomy. World J Clin Cases. 2:32-35.
53. Tang, N., Li, D., Wang, X., Sun, Z., 2020. Abnormal coagulation parameters are associated with poor prognosis in patients with novel coronavirus pneumonia. J Thromb Haemost. 18:844-847
54. Tang, Y.W., Schmitz, J.E., Persing, D.H., Stratton, C.W., 2020. Laboratory Diagnosis of COVID-19: Current Issues and Challenges. J Clin Microbiol. 58:e00512-00520.
55. Templin C., Ghadri J.R., Diekmann J., Napp L.C., Bataiosu D.R., Jaguszewski M., et al., 2015. Clinical Features and Outcomes of Takotsubo (Stress) Cardiomyopathy. N Engl J Med. 373:929-938.
56. Tilling, L., Becher, H., 2007. The vanishing vast ventricular thrombus. Eur J Echocardiogr. 8:67-70.
57. Tsamakis, K., Rizos, E., Manolis, A.J., Chaidou, S., Kympouropoulos, S., Spartalis, E., et al., 2020. COVID-19 pandemic and its impact on mental health of healthcare professionals. Exp Ther Med. 19:3451-3453.
58. Ueyama, T., Kasamatsu, K., Hano, T., Yamamoto, K., Tsuruo, Y., Nishio, I., 2002. Emotional stress induces transient left ventricular hypocontraction in the rat via activation of cardiac adrenoceptors: a possible animal model of 'tako-tsubo' cardiomyopathy. Circ J. 66:712-713.
59. Xiang, Y.T., Yang, Y., Li, W., Zhang, L., Zhang, Q., Cheung, T., Ng, CH., 2020. Timely mental health care for the 2019 novel coronavirus outbreak is urgently needed. Lancet Psychiatry. 7:228-229.
60. Vasilieva, E., Vorobyeva, I., Lebedeva, A., Urazovskaya, I., Kalinskaya, A., Skrypnik, D., Shpektor, A., 2011. Brachial artery flow-mediated dilation in patients with Tako-tsubo cardiomyopathy. Am J Med. 124:1176-1179.
61. Wittstein, I.S., Thiemann, D.R., Lima, J.A., Baughman, K.L., Schulman, S.P., Gerstenblith, G., et al., 2005. Neurohumoral features of myocardial stunning due to sudden emotional stress. N Engl J Med. 352:539-548.
62. Wiyono, S.A., Vletter, W.B., Soliman, O.I., ten Cate, F.J., Geleijnse, M.L., 2010. Thrombus in a normal left ventricle: a cardiac manifestation of pheochromocytoma. Echocardiography. 27:195-197.
63. Wybraniec, M., Mizia-Stec, K., Krzych, L., 2014. Stress cardiomyopathy: yet another type of neurocardiogenic injury: 'stress cardiomyopathy'. Cardiovasc Pathol. 23:113-120.