Table of Contents  
CASE REPORT
Year : 2013  |  Volume : 6  |  Issue : 4  |  Page : 459-461  

A case of chronic left ventricular thrombus with ischemic cardiomyopathy


Department of Medicine, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune, India

Date of Web Publication17-Sep-2013

Correspondence Address:
Vikram Bhausaheb Vikhe
Department of Medicine, Padmashree Dr. D. Y. Patil Medical College, Hospital and Research Centre, Dr. D. Y. Patil Vidyapeeth, Pimpri, Pune
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0975-2870.118289

Rights and Permissions
  Abstract 

Left ventricular (LV) thrombus is a serious complication of anterior wall myocardial infarction (MI), especially in patients with severe LV dysfunction. LV thrombus carries a high risk of causing stroke and other thromboembolic complications despite adequate anticoagulation therapy. There is a benefit of anticoagulation in patients with ischemic cardiomyopathy to reduce thromboembolic events or in resolution of LV thrombus. Two-dimensional (2D) echocardiography is the most commonly used technique for the diagnosis and follow-up of such cases. Our patient developed a chronic LV thrombus with ischemic cardiomyopathy post anterior wall MI and was managed well on anticoagulants to prevent the thromboembolic events under strict vigilance and follow-up.

Keywords: 2D echocardiography, anticoagulation, LV dysfunction, LV thrombus, myocardial infarction


How to cite this article:
Vikhe VB, Gupta A, Shende P. A case of chronic left ventricular thrombus with ischemic cardiomyopathy. Med J DY Patil Univ 2013;6:459-61

How to cite this URL:
Vikhe VB, Gupta A, Shende P. A case of chronic left ventricular thrombus with ischemic cardiomyopathy. Med J DY Patil Univ [serial online] 2013 [cited 2022 Aug 17];6:459-61. Available from: https://www.mjdrdypu.org/text.asp?2013/6/4/459/118289


  Introduction Top


Left ventricular (LV) thrombus occurs in case of impaired LV dysfunction as a result of ischemic cardiomyopathy, aneurysm, or a myocardial infarction (MI). [1],[2] LV thrombus is a well-recognized complication of acute MI. [2],[3] Approximately 40-60% of patients with extensive anterior wall MI (AWMI) develop LV thrombus. [3] Due to the high risk of thromboembolic events, early and accurate detection of LV thrombus is very important. [3] These thromboembolic events can be prevented by long-term use of systemic anticoagulation. [2],[4] Two-dimensional (2D) echocardiography plays a pivotal role in determining the natural course of LV thrombus formation in post-MI patients. [3]


  Case Report Top


We report the case of a 50-year-old male who presented with acute-onset left-sided chest pain, constricting type, non-radiating, associated with profuse sweating, restlessness, and palpitations. His general, physical, and systemic examination was unremarkable. His electrocardiogram (ECG) was suggestive of antero-septal and lateral wall MI. His serum creatine phosphokinase-MB CPK-MB levels were elevated and troponin-T was positive. After this, he was thrombolysed with streptokinase. Rest of the hematological investigations were within normal limits. His past history revealed that he was a tobacco chewer for past 30 years and hypertensive since 2 years and was taking Tab. amlodipine 5 mg OD. 2D echocardiography revealed anterior wall, anterior septum, and lateral wall akinesia. Left ventricular ejection fraction (LVEF) was 20%. There was presence of an LV thrombus measuring 2.3 × 3.5 cm at the apex. His coronary angiography (CAG) showed right coronary artery (RCA) dominance. CAG revealed a plaque causing 40% stenosis in the proximal RCA and diffuse disease followed by total occlusion in the mid RCA, whereas the distal RCA showed retrograde filling from the left anterior descending (LAD) artery. In the left coronary artery, the LAD showed minor plaques, whereas the mid, distal, and diagonals were normal. Patient was discharged on ramipril, aspirin, clopidogrel, atorvastatin, furosemide, spironolactone, and warfarin. He was advised for a regular follow-up and lifestyle modifications. His prothrombin time/international normalized ratio PT/INR and warfarin dose were monitored and adjusted accordingly in the follow-up visits. Patient was stable for 4 months after which he developed unstable angina. This time he was treated with enoxaparin 60 mg BD for 5 days. 2D echocardiography this time revealed ischemic cardiomyopathy with all four chambers dilated. LVEF was 25%. A large thrombus measuring 3.2 × 3.0 cm was seen at the apex. Inferior vena cava was dilated and there was severe pulmonary hypertension with tricuspid regurgitation. The anterior wall and interventricular septum of LV were akinetic and apex was dyskinetic. Patient's symptoms were relieved in the next few days and he was discharged on the same above-mentioned treatment. Oral warfarin was continued and adjusted according to the PT/INR values [Figure 1] and [Figure 2].
Figure 1: Image showing left ventricular thrombus

Click here to view
Figure 2: Image showing the big left ventricular clot with measurements and dilated left ventricle

Click here to view



  Discussion Top


LV thrombus is a serious complication of the anterior wall MI, especially in patients with severe LV dysfunction as it was the case in our patient. [5] The development of most thrombi takes place within the first 2 weeks after acute MI or within few hours after extensive AWMI. [3] LV thrombus in our patient was diagnosed by 2D echocardiography after 2 days of acute MI. LV thrombus carries a high risk of causing stroke and other thromboembolic complications despite adequate anticoagulation therapy. [6] In patients with cardiomyopathy, the incidence of LV thrombus has been reported in the literature as 11-44%. [6] The definitive treatment of LV thrombus is controversial. The main treatment options include thrombectomy, anticoagulation, and thrombolysis. [1],[2] Many studies report a benefit of anticoagulation in patients with ischemic cardiomyopathy to reduce the thromboembolic events or in resolution of LV thrombus. [1],[2] In case of mobile and pedunculated thrombi, surgical removal is generally recommended because they have a significantly higher risk of systemic embolization. [1],[7] 2D echocardiography is the most commonly used technique for diagnosis and follow-up of such cases. It has a sensitivity of 92-95% and a specificity of 86-88% for the diagnosis of LV thrombus. [8]


  Conclusion Top


In our case, the patient was admitted again with unstable angina. He had stenosis in RCA and an episode of acute MI 4 months back; therefore, he is prone for such events in future also. Furthermore, LV thrombus by itself can complicate MI, where akinesia causes blood stasis and the formation of LV thrombus. [9] Our patient had developed a chronic LV thrombus probably due to LV dysfunction and ischemic cardiomyopathy causing blood stasis. [9] The incidence of LV thrombus in patients with cardiomyopathy has been reported in the literature as 11-44%. [1],[6] He was managed well on anticoagulants to prevent the thromboembolic events, but he is still at high risk of developing thromboembolic events in future as embolization to the peripheral vessels, especially cerebral vessels being the most common, is well known. [10]

Consent

Written informed consent was obtained from the patient for publication of this case report and any accompanying images.

 
  References Top

1.Jeon GJ, Song BG, Kim TH, Yang HJ, Ma BO, Park YH, et al. Catastrophic massive intracardiac thrombus in a 40-year-old patient with dilated cardiomyopathy. Nepal Med Coll J 2011;13:226-8.  Back to cited text no. 1
[PUBMED]    
2.Nixon JV. Left ventricular mural thrombus. Arch Intern Med 1983;143:1567-71.  Back to cited text no. 2
[PUBMED]    
3.Potu C, Tulloch-Reid E, Baugh D, Madu E. Left ventricular thrombus in patients with acute myocardial infarction: Case report and Caribbean focused update. Australas Med J 2012;5:178-83.  Back to cited text no. 3
[PUBMED]    
4.Kyrle PA, Korninger C, Gössinger H, Glogar D, Lechner K, Niessner H, et al. Prevention of arterial and pulmonary embolism by oral anticoagulants in patients with dilated cardiomyopathy. Thromb Haemost 1985;54:521-3.  Back to cited text no. 4
    
5.Cheng TC. Refractory left ventricular failure: Use of two-dimensional echocardiography in identification of thrombi. Postgrad Med 1982;72:135-8,142.  Back to cited text no. 5
[PUBMED]    
6.Sharma ND, McCullough PA, Philbin EF, Weaver WD. Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction. Chest 2000;117:314-20.  Back to cited text no. 6
[PUBMED]    
7.Nili M, Deviri E, Jortner R, Strasberg B, Levy MJ. Surgical removal of a mobile, pedunculated left ventricular thrombus: Report of 4 cases. Ann Thorac Surg 1988;46:396-400.  Back to cited text no. 7
[PUBMED]    
8.Stratton JR, Lighty GW Jr, Pearlman AS, Ritchie JL. Detection of left ventricular thrombus by two-dimensional echocardiography: Sensitivity, and causes of uncertainty. Circulation 1982;66:156-66.  Back to cited text no. 8
[PUBMED]    
9.Meltzer RS, Visser CA, Fuster V. Intracardiac thrombi and systemic embolization. Ann Intern Med 1986;104:689-98.  Back to cited text no. 9
[PUBMED]    
10.Stokman PJ, Nandra CS, Asinger RW. Left ventricular thrombus. Curr Treat Options Cardiovasc Med 2001;3:515-21.  Back to cited text no. 10
[PUBMED]    


    Figures

  [Figure 1], [Figure 2]



 

Top
   
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Case Report
Discussion
Conclusion
References
Article Figures

 Article Access Statistics
    Viewed2966    
    Printed94    
    Emailed0    
    PDF Downloaded237    
    Comments [Add]    

Recommend this journal