Title: AN INTERESTING CASE OF LAYERED LEFT VENTRICULAR THROMBUS - MURAL STACKING OF VENTRICULAR APEX
Abstract: TOPIC: Cardiovascular Disease TYPE: Medical Student/Resident Case Reports INTRODUCTION: Left ventricular thrombus (LV-T) is a dreadful complication of acute anterior wall myocardial infarction and heart failure with reduced ejection fraction (HFrEF). Despite percutaneous coronary intervention (PCI) and oral anticoagulation, prevalence of LV-T remains high. We present a rare manifestation of a thrombus in the left ventricle (LV), of a layered morphology, obscuring the entire apical segment with complete apical akinesis despite a PCI and continued oral anticoagulation (OAC). CASE PRESENTATION: We present a 51-year-old male with a past medical history of ischemic cardiomyopathy with left ventricular ejection fraction (LVEF) <20% status post biventricular pacemaker placement, paroxysmal atrial fibrillation on warfarin, hypothyroidism, history of cocaine and alcohol abuse, and anterior wall myocardial ischemia presented with acute onset of sharp, left-sided chest pain and dyspnea at rest. EKG showed normal sinus rhythm without any ST changes and unremarkable troponin levels. Echocardiogram showed LVEF <20% with severe apical akinesis with a unique finding of layered LV-T thrombus which was large, immobile, 3.5 cm in diameter and adherent to the left ventricular apical wall. Subtherapeutic INR was noted despite confirmed coumadin compliance. Patient was bridged with enoxaparin, until therapeutic INR was attained with warfarin. Follow-up with an anticoagulation clinic and a cardiac MRI was arranged. DISCUSSION: LV-T has been commonly observed in acute anterior myocardial infarction and HFrEF. An LV-T with a reduced LVEF can have fatal consequences like systemic thromboembolism and ischemic stroke. PCI has significantly reduced the prevalence of LV-T with estimates ranging between 5-15% [1, 2]. Nevertheless, incidence of LV-T continues to remain high (35%) despite PCI, especially for acute myocardial infarction involving the anterior wall. Current guidelines recommend anticoagulation with warfarin for 3 months, or longer if thrombus persists. Our patient developed progressive thrombus despite being on warfarin and aspirin. LV-T is commonly categorized by shape, as protruding (projects into the cavity) or mural (appears flat and parallel to the endocardial surface). However, considering morphology and spontaneous time course variations to motions and dynamics, this case has a rare progressive presentation identified as 'layered'. Cardiac MRI is highly encouraged for further monitoring. Use of thrombolytic or fibrinolytic agents capable of lysing ventricular thrombi would be an aggressive therapeutic approach, not commonly implemented due to the high risks associated with it. CONCLUSIONS: Appearance of a layered LV-T should be managed with aggressive therapy as it often does not resolve with routine medical management. REFERENCE #1: Ali, Z., Isom, N., Dalia, T., Sami, F., Mahmood, U., Shah, Z., & Gupta, K. (2020). Direct oral anticoagulant use in left ventricular thrombus. Thrombosis journal, 18(1), 1-4. REFERENCE #2: Types/ Mohammed Abdullahi Talle, Faruk Buba, Charles Oladele Anjorin, "Prevalence and Aetiology of Left Ventricular Thrombus in Patients Undergoing Transthoracic Echocardiography at the University of Maiduguri Teaching Hospital", Advances in Medicine, vol. 2014, Article ID 731936, 8 pages, 2014. https://doi.org/10.1155/2014/731936 DISCLOSURES: No relevant relationships by Tapan Buch, source=Web Response No relevant relationships by Ajinkya Buradkar, source=Web Response No relevant relationships by Kashyap Kela, source=Web Response no disclosure on file for Pooja Kharbanda; No relevant relationships by Princy Shah, source=Web Response