Embolic complication of Tako-Tsubo cardiomyopathy

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. Electrocardiogram showing ST depression in the inferolateral leads and ST elevation in aVR and V1-2. 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. Catheterization demonstrating occlusion of the distal right popliteal and anterior tibial arteries. Echocardiogram (apical four chamber view) 4 weeks later demonstrating normal left ventricular ejection fraction. A: end diastole and B: end systole.