Intraventricular thrombus in Takotsubo syndrome: Incidence, predictors, management, and prognosis. Insights from the RETAKO registry.

Background: Takotsubo syndrome (TTS) is characterized by transient left ventricular (LV) dysfunction and wall motion abnormalities without culprit coronary artery disease. LV thrombus (LVT) formation during the acute phase is a fearsome complication.

Objectives: To identify factors associated with LVT and its prognostic impact in TTS patients.

Methods: Data from the nationwide REgistry on TAKOtsubo syndrome (RETAKO), which combines retrospective (2002-2012) and prospective (2012 onwards) recruitment with prospective follow-up, were reviewed to assess patient characteristics, imaging findings, and clinical outcomes according to the presence of LVT.

Results: Of 1478 TTS consecutive patients (median age 72 years, 13.5 % men), 42 patients (2.8 %) presented with LVT. Presentation with syncope, a typical "apical ballooning" pattern, the presence of late gadolinium enhancement (LGE) on cardiac magnetic resonance imaging, and elevated high sensitivity-C reactive protein (hs-CRP), were associated with LVT. On multivariable analysis, elevated hs-CRP at admission and LGE persisted as independent predictors of LV thrombus. Patients with LVT had higher rates of in-hospital major bleeding (9.5 % vs. 3.1 %, p = 0.023) and major adverse cardiovascular events (26.8 % vs. 15.2 %, p = 0.035), mainly driven by stroke (14.6 % vs. 2.5 %, p < 0.001) and systemic embolism (19 % vs. 1.3 %, p < 0.001). At a median follow-up of 18 months, there were no differences in mortality, cardiac readmissions, or TTS recurrence between groups.

Conclusions: In TTS patients, elevated hs-CRP and LGE are associated with a higher risk of LVT. Although LVT is rare, it is associated with increased in-hospital thromboembolic events and bleeding, while long-term outcomes are comparable to those without LVT.

Clinical Perspective: What is new? In patients with TTS, the presence of LVT is linked to worse in-hospital outcomes, although it does not significantly affect long-term follow-up. Identifying imaging and laboratory predictors, such as elevated high-sensitivity C-reactive protein (hs-CRP) and late gadolinium enhancement (LGE) on cardiac MRI, can help clinicians identify patients at higher risk for LV thrombus formation. What are the clinical implications? TTS patients with LV thrombi may benefit from intensive in-hospital monitoring and closer clinical follow-up to manage and mitigate potential adverse events. Similarly, patients presenting with factors associated with LV thrombi, such as elevated hs-CRP and LGE, should be closely monitored for thrombus presence or development.