5). Fig. 5 Transthoracic echocardiographic image obtained after 1 week of anticoagulation therapy shows near normal left ventricular wall motion and complete resolution of the apical thrombus. Discussion

Takotsubo cardiomyopathy (stress-induced cardiomyopathy) is a relatively novel cardiac syndrome characterized by peculiar transient LV dysfunction. Approximately Inhibitors,research,lifescience,medical 1-3% of the patients with stress-induced cardiomyopathy show symptoms that initially mimic acute coronary syndrome.3),5) In this case, we did not performed coronary angiography, but we could tentatively diagnose as stress-induced cardiomyopathy because of the absent of buy ATM Kinase Inhibitor cardiovascular symptom and no serial changes of cardiac biomarkers in septic patient. Despite the favorable prognosis, certain serious complications have been reported in patients with stress-induced cardiomyopathy, such as acute decompensated heart failure, ventricular arrhythmia, LV rupture, and LV thrombus.4),7-12) Inhibitors,research,lifescience,medical Thrombus formation in such cases was probably related to transient apical asynergy combined with increased sympathetic activation,

which alters the coagulation cascade. To date, the true incidence and clinical significance of LV thrombus and Inhibitors,research,lifescience,medical the related embolic outcomes in patients with stress-induced cardiomyopathy have not been fully established. Haghi et al.11) reported an 8% incidence Inhibitors,research,lifescience,medical of LV thrombus in the study population, but a much lower incidence of accompanying embolic complications. They concluded

that LV thrombus can occur at the initial presentation or any time later during the disease. In our patient, the initial echocardiogram showed only apical ballooning and akinesia without any evidence of LV apical Inhibitors,research,lifescience,medical thrombus; however, thrombus formation occurred after a week and led to cerebral infarction. In a systematic review, de Gregorio et al.13) found that among 15 Takotsubo cardiomyopathy patients with ventricular thrombosis, 5 patients suffered from thromboembolic events, 3 of whom developed stroke. Therefore, physicians should be aware of this complication. The current treatment of stress-induced cardiomyopathy consists of Carnitine palmitoyltransferase II supportive care and standard treatments for LV systolic dysfunction. The role of anticoagulation therapy has not yet been defined. To the best of our knowledge, there are no published guidelines for the management of stress-induced cardiomyopathy with LV thrombus. However, some reports mention that short-term anticoagulation therapy with heparin and warfarin for several weeks resolved LV thrombus.8),9),11) In this case, LV thrombus was resolved after 1 week of anticoagulation therapy. From our review, we conclude that patients with stress-induced cardiomyopathy appear to be at a significant risk for development of thrombus and subsequent stroke because of the marked apical wall motion abnormality.