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 Table of Contents  
INTERESTING CASE REPORT
Year : 2019  |  Volume : 3  |  Issue : 2  |  Page : 107-108

A large undulating left ventricular apical thrombus encroaching up to aortic valve


Department of Cardiology, S.N. Medical College, Jodhpur, Rajasthan, India

Date of Web Publication29-Aug-2019

Correspondence Address:
Swati Mahajan
R/O C-9 Shastri Nagar, Jodhpur - 342 003, Rajasthan
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiae.jiae_1_19

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  Abstract 

Left ventricular (LV) thrombus is a serious complication of acute myocardial infarction (MI) with the risk of systemic thromboembolism. Two-dimensional echocardiography (2D-Echo) allows detection and is an important tool for the follow-up of such cases. Our patient had suffered from an acute ischemic stroke and was referred by the treating neurologist for changes in the electrocardiogram. The patient had anterior wall MI, and 2D-echo showed a large LV thrombus. He was started on anticoagulants to prevent future thromboembolic events.

Keywords: Anticoagulation, left ventricular thrombus, thromboembolism


How to cite this article:
Sanghvi S, Mahajan S. A large undulating left ventricular apical thrombus encroaching up to aortic valve. J Indian Acad Echocardiogr Cardiovasc Imaging 2019;3:107-8

How to cite this URL:
Sanghvi S, Mahajan S. A large undulating left ventricular apical thrombus encroaching up to aortic valve. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2019 [cited 2019 Sep 15];3:107-8. Available from: http://www.jiaecho.org/text.asp?2019/3/2/107/265745


  Introduction Top


Postmyocardial infarction (MI) left ventricular (LV) thrombus is a common complication, the incidence being as high as 15% with ST-elevation MI, of which 25% occur in patients of anterior wall MI (AWMI), according to the contemporary data.[1] Due to the high risk of thromboembolism associated with an LV thrombus, its early detection and optimal management with anticoagulation are extremely important. In our case, the patient had a large LV thrombus and had already suffered from thromboembolic complication. Our case reflects the importance of early detection of the LV thrombus, as early institution of the anticoagulation may prevent the occurrence of the systemic embolization.


  Clinical Presentation Top


A 50-year-old male, with a history of cerebrovascular accident, ischemic stroke with right-sided hemiparesis, partially recovered, was referred by the neurologist for changes in electrocardiogram (ECG). He did not have any history of coronary artery disease (CAD) in the past. His ECG revealed normal sinus rhythm with ST-elevation in the precordial leads, suggestive of AWMI. Two-dimensional (2D) transthoracic echocardiography revealed akinetic apex, distal interventricular septum (IVS), mid-inferior septum, apico-inferior, apico-anterior, apicolateral, and mid-anterior wall. A large LV apical thrombus (42 mm × 34 mm) was seen which extended along the IVS. Its distal part was mobile and encroached onto the aortic valve [Figure 1], creating turbulence to the flow across LV outflow tract (LVOT) [Figure 2]. The ejection fraction was estimated to be 20% by Simpson's biplane method of disks. The patient was immediately started on anticoagulation and closely monitored.
Figure 1: Two-dimensional echocardiography showing large left ventricular thrombus, extending along the interventricular septum encroaching onto the aortic valve

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Figure 2: Pulsed-wave Doppler showing increased flow velocities across left ventricular outflow tract

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  Discussion Top


Risk factors for the development of LV thrombus are consistent, irrespective of infarct treatment and include large infarct size, apical akinesia or dyskinesia, LV aneurysm, and AWMI.[2] Rarely, hypercoagulable or inflammatory states may be predisposing factors for LV thrombus formation.[3],[4] Early data from the prethrombolytic and thrombolytic eras suggest that in the setting of acute MI, LV thrombus was present in 7%–46% of patients, most frequently in acute anterior or apical MI.[2],[5],[6] Nowadays, the reported incidence is lower. The major concern for LV thrombus is its thromboembolic potential causing morbidity and mortality. Hence, early detection using 2D-Echo can allow timely institution of anticoagulation and prevention of thromboembolism.

In our case, the patient neither had any history of CAD in the past nor did he have any history of recent angina. He had suffered a silent MI and had not received any thrombolytic or anticoagulant therapy for the same. Due to lack of thrombolysis/anticoagulant therapy at the time of MI, a large area of akinesia, and poor LV systolic function, he developed a large LV thrombus and had already suffered from the thromboembolic complication in the form of an ischemic stroke.


  Conclusion Top


Post-MI development of LV thrombus is common, and there have been case reports on the same. Our case is unique in the extent of the thrombus from the apex along the IVS, which further encroached onto the aortic valve, producing turbulence across LVOT.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Solheim S, Seljeflot I, Lunde K, Bjørnerheim R, Aakhus S, Forfang K, et al. Frequency of left ventricular thrombus in patients with anterior wall acute myocardial infarction treated with percutaneous coronary intervention and dual antiplatelet therapy. Am J Cardiol 2010;106:1197-200.  Back to cited text no. 1
    
2.
Asinger RW, Mikell FL, Elsperger J, Hodges M. Incidence of left-ventricular thrombosis after acute transmural myocardial infarction. Serial evaluation by two-dimensional echocardiography. N Engl J Med 1981;305:297-302.  Back to cited text no. 2
    
3.
Schneider C, Bahlmann E, Heuser C, Antz M, Kron O, Schmitz N, et al. Images in cardiovascular medicine. Unusual biventricular thrombus formation in acute myeloid leukemia and factor V Leiden mutation. Circulation 2003;107:e114-6.  Back to cited text no. 3
    
4.
Vanhaleweyk G, el-Ramahi KM, Hazmi M, Sieck JO, Zaman L, Fawzy M, et al. Right atrial, right ventricular and left ventricular thrombi in (incomplete) Behçet's disease. Eur Heart J 1990;11:957-9.  Back to cited text no. 4
    
5.
Visser CA, Kan G, Lie KI, Durrer D. Left ventricular thrombus following acute myocardial infarction: A prospective serial echocardiographic study of 96 patients. Eur Heart J 1983;4:333-7.  Back to cited text no. 5
    
6.
Jugdutt BI, Sivaram CA. Prospective two-dimensional echocardiographic evaluation of left ventricular thrombus and embolism after acute myocardial infarction. J Am Coll Cardiol 1989;13:554-64.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2]



 

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