Abstract 16199: Postsurgical Takotsubos Complicated by Clot Burden in the Setting of Heterozygous Prothrombin Gene Mutation

Abstract

Introduction: Postsurgical Takotsubo cardiomyopathy (TCM) is associated with acute stress secondary to catecholamine release causing reversible left ventricular (LV) failure. We present a diagnostically challenging presentation of postsurgical TCM with underlying prothrombin gene mutation. Case Presentation: A 53 year old female underwent laparoscopic hysterectomy 2 days prior to presentation with chest pain and shortness of breath. Vitals were unremarkable, labs showed elevated troponin and EKG consistent with NSTEMI. CTA chest demonstrated significant clot burden to the ascending and descending aorta. Echocardiogram revealed a reduced ejection fraction (EF) of 25-30% with apical ballooning and thrombus. She was admitted on heparin drip and completed an infusion of eptifibatide for 24 hours. Repeat CTA chest demonstrated mildly reduced clot burden. Left heart catheterization (LHC) was precluded due to aortic arch clot. Coronary CTA revealed no CAD with a calcium score of 0. Coagulopathy workup showed heterozygous prothrombin G20210A variant. She was discharged on warfarin. Repeat echocardiography 1 month later showed improved EF to 40-45%. Discussion: TCM accounts for 1-3% of cases of acute coronary syndromes (ACS) and affects women at a rate of 90%. Studies have shown that TCM with apical ballooning is minimally associated with LV thrombus . The presence of heterozygous prothrombin gene mutation increases risk of clot formation by 2 to 3 times. Surgery can cause this risk to dramatically increase. Coronary CTA was the best noninvasive approach to make the diagnosis as the risk of LHC was too great given the anatomic challenge of the aortic arch clot. We advocate for hypercoagulable workups to inform management of anticoagulation in patients with clotting events without known risk factors for thrombus formation.