Takotsubo syndrome complicated by left ventricular thrombus and free wall rupture leading to cardiac arrest: a case report of successful life-saving surgical treatment.

Background: Takotsubo syndrome (TTS) is a stress-induced cardiomyopathy that causes transient left ventricular dysfunction. Although generally considered benign, TTS occasionally leads to serious complications such as cardiac rupture or left ventricular thrombus, both of which carry significant risks. Case summary: A 69-year-old woman presented to our hospital with dyspnoea after physical and emotional stress. Based on the findings of ST-segment elevation on an electrocardiogram and wall motion abnormality of the left ventricular apex on echocardiography, an acute coronary syndrome was suspected. Emergency coronary angiography showed no significant stenosis in the coronary artery, but left ventriculography showed typical apical ballooning, consistent with TTS. Anticoagulation with heparin was initiated to prevent left ventricular thrombus formation. On the fifth day after admission, echocardiography revealed a left ventricular apical thrombus and slight pericardial effusion, which developed into cardiac tamponade on day 6. While being prepared for emergency surgery, the patient was diagnosed with cardiac rupture and went into cardiac arrest. Therefore, venous-arterial extracorporeal membrane oxygenation was initiated prior to the surgical procedure. Successful repair of the ruptured free wall site in the left ventricular anterolateral region resulted in complete recovery. The patient was discharged on day 35. Discussion: To our knowledge, this is the first case of TTS complicated by cardiac rupture during anticoagulation treatment for a left ventricular thrombus. Although anticoagulation therapy may have precipitated the bleeding associated with cardiac rupture, the early diagnosis of TTS complications and prompt management, including emergency surgery, may have contributed to the patient's favourable outcome.