Sir,

We present a case of an 81-year-old female presenting with one week worsening dyspnea on exertion and a cold, discolored, numb foot for 2 days. The patient denied chest pain but reported a history consistent with melanotic stools. Her hemoglobin was found to be 3.5 in the emergency department. Electrocardiogram showed 0.5–1.0 mm ST depression in leads II, III, aVF, V4-6 and ST elevation in aVR and V1-2 (Figure 1). Echocardiogram demonstrated a dilated left ventricle with a severely reduced ejection fraction but preserved basal contractile function (Figure 2A: end diastole and B: end systole). Catheterization demonstrated no epicardial coronary artery disease, but occlusion of the distal right popliteal and anterior tibial arteries (Figure 3). The patient was treated with heparin, aspirin, beta-blocker and angiotensin converting enzyme inhibitor. The patient eventually required amputation of her right lower extremity. Gastroenterological workup revealed a colon adenocarcinoma which was successfully resected. Follow-up echocardiogram 4 weeks later demonstrated normal left ventricular ejection fraction (Figures 4A: end diastole and 4B: end systole). The final diagnosis was tako-tsubo cardiomyopathy, precipitated by severe anemia, leading to distal thrombus embolization. Haghi et al.1 reported in this journal the incidence of left ventricular thrombus in the setting of tako-tsubo cardiomyopathy to be 8%. However, they reported no episodes of peripheral embolization due to the left ventricular thrombus. This case illustrates the potential complications associated with thrombus formation found to occur in a minority of tako-tsubo cardiomyopathy cases.

Figure 1.

Electrocardiogram showing ST depression in the inferolateral leads and ST elevation in aVR and V1-2.

Figure 1.

Electrocardiogram showing ST depression in the inferolateral leads and ST elevation in aVR and V1-2.

Figure 2.

Echocardiogram (apical four chamber view) demonstrating a dilated left ventricle with severely reduced ejection fraction but preserved basal contractile function. A: end diastole and B: end systole.

Figure 2.

Echocardiogram (apical four chamber view) demonstrating a dilated left ventricle with severely reduced ejection fraction but preserved basal contractile function. A: end diastole and B: end systole.

Figure 3.

Catheterization demonstrating occlusion of the distal right popliteal and anterior tibial arteries.

Figure 3.

Catheterization demonstrating occlusion of the distal right popliteal and anterior tibial arteries.

Figure 4.

Echocardiogram (apical four chamber view) 4 weeks later demonstrating normal left ventricular ejection fraction. A: end diastole and B: end systole.

Figure 4.

Echocardiogram (apical four chamber view) 4 weeks later demonstrating normal left ventricular ejection fraction. A: end diastole and B: end systole.

References

1
Haghi
D
Papavassiliu
T
Heggemann
F
Kaden
JJ
Borggrefe
M
Suselbeck
T
Incidence and clinical significance of left ventricular thrombus in tako-tsubo cardiomyopathy assessed with echocardiography
QJM
 , 
2008
, vol. 
101
 (pg. 
381
-
6
)