Correspondence Address: Dr. Sunil Gurmukhani 9, Vivan Karma, Bunglows, Near Keshav Baug Party Plot, Shivranjani, Ahmedabad - 380 015, Gujarat India
Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jiae.jiae_8_20
Abstract
Left ventricular (LV) cavity mass is common in clinical practice. Most of the time, it is a thrombus at the LV apex. Nonapical location of mass leads to confusion in the diagnosis with possibilities of tumors or vegetations. Here, we describe a case of LV thrombus in an extremely unusual location. Multimodality images helped us to come to a proper diagnosis. The mass vanished completely from LV cavity with medical management. Our case is unique, as presentation of clot was at very unusual location, only few such cases have been reported in literature. With the help of multimodality imaging, we were able to successfully manage the case conservatively with oral anticoagulation. Left ventricular thrombus is a common complication in patient with ischemic or nonischemic cardiomyopathy. Nonapical location of a thrombus is not only extremely rare but also creates diagnostic confusion. Although echocardiography is a screening imaging modality of choice, magnetic resonance imaging is extremely useful before planning surgical versus nonsurgical treatment option.
Keywords: Left ventricular mass, left ventricular thrombus, vanishing tumor of the heart
How to cite this article: Gurmukhani S, Gupta D, Mutha S, Patel A, Shah S, Patel T. Vanishing Tumor of the Heart: Very Unusual Location of Left Ventricular Thrombus. J Indian Acad Echocardiogr Cardiovasc Imaging 2020;4:390-2
How to cite this URL: Gurmukhani S, Gupta D, Mutha S, Patel A, Shah S, Patel T. Vanishing Tumor of the Heart: Very Unusual Location of Left Ventricular Thrombus. J Indian Acad Echocardiogr Cardiovasc Imaging [serial online] 2020 [cited 2021 Apr 13];4:390-2. Available from: https://www.jiaecho.org/text.asp?2020/4/3/390/303952
Introduction
Left ventricular (LV) cavity mass is one of the rare findings which may lead to systemic embolization, obstruction, or arrhythmias. The most common cause of intracavitary mass is LV thrombus secondary to ischemic insult. However, other less frequent causes could be vegetation, fibroma, myxoma, secondaries, papillary muscle hypertrophy, and artifact. LV thrombus is usually associated with coronary artery disease, LV aneurysm, cardiomyopathy, and myocarditis. Other rare causes of LV thrombus include hypercoagulable states, systemic lupus erythematosus, Sweet's syndrome, Behcet's disease, and Takotsubo cardiomyopathy.[1],[2],[3],[4],[5] The incidence of LV thrombus has decreased in the primary percutaneous coronary intervention era compared with the thrombolytic era, but it still occurs in the range of 2.9%–15%.[6] The most common location of LV thrombus is at the LV apex. Nonapical location of the thrombus in LV cavity is extremely rare and difficult to differentiate from other etiologies of LV mass. Thrombus presenting at nonapical site has higher chances of embolization too. Echocardiography is first-line screening imaging modality of choice. However, in case of atypical location of mass, magnetic resonance imaging (MRI) helps to differentiate. Here, we describe a case of LV thrombus at extremely unusual location in a patient of nonischemic cardiomyopathy which mimics mass lesion. Multimodality imaging helped us to come to the diagnosis of LV thrombus. The mass disappeared completely with anticoagulation in 3 weeks.
Clinical Presentation
Hypertensive nondiabetic male in his 50s sought medical attention due to shortness of breath on minimal exertion for 6 months which was of New York Heart Association III, without any associated history of paroxysmal nocturnal dyspnea or orthopnea. Previous medical history was unremarkable except for recently detected hypertension. Clinical examination revealed S3 at the cardiac apex with mild basal crepitation in both lung fields occupying less than one-third of the lung fields. His electrocardiography was unremarkable. Chest X-ray was showing borderline cardiomegaly with signs of grade II pulmonary venous congestion. His brain naturetic peptide levels were significantly raised. Two-dimensional echocardiography showed two ovoid highly mobile echogenic masses with central hypolucency attached to the basal posteromedial wall in modified parasternal long axis view and short axis view [Figure 1]a and [Figure 1]b and [Supplementary Video 1] and [Supplementary Video 2]. LV ejection fraction was 15% with global hypokinesia. Transesophageal echocardiography images confirmed the fragile echogenic structure attached to the mural surface of the LV basal posteromedial wall [Figure 1]c and [Supplementary Video 3]. Three-dimensional echo view showed a dumbbell-like highly mobile structure attached on the mural surface of LV [Figure 2]a and [Figure 2]b and [Supplementary Video 4] and [Supplementary Video 5]. Background LV dysfunction and echogenic properties of mass were favoring thrombus, but the location was not favoring our diagnosis. Hence, we requested for cardiac MRI. Cardiac MRI confirmed the diagnosis of LV thrombus [Figure 2]c and [Supplementary Video 6]. We kept patient on low molecular weight heparin, followed by oral anticoagulation for 3 weeks along with guidelines directed medical therapy for LV dysfunction. We did serial echo studies to see for any change in LV mass. We found a gradual reduction of size of the thrombus and complete resolution of the thrombus [Figure 3]a and [Figure 3]b and [Supplementary Video 7] and [Supplementary Video 8] by 3 weeks without any clinical evidence of systemic embolization. After 3 weeks, we did selective angiography to rule out coronary artery disease which was normal. We put the diagnosis of nonischemic cardiomyopathy and treated patient accordingly.
Figure 1: Two small echogenic masses attached to the basal inferoposterior wall of the left ventricle in modified parasternal view. (b) Small echogenic mass attached to the basal inferoposterior wall of the left ventricle in short axis view. (c) Transesophageal view showing mass attached to the mural surface of the left ventricle
Figure 2: (a and b) Three-dimensional echocardiographic views showing mass attached to the mural surface of the left ventricle. (c) Magnetic resonance imaging images showing mass attached to the inferoposterior wall of the left ventricle
Intracavitary LV mass has multiple differential diagnosis. The most common differential is LV thrombus. Thrombus is usually located at the LV apex. Nonapical location of thrombus is a very rare occurrence due to flow velocity differences. Diagnostic dilemma arises particularly when the thrombus is located at nonapical location in the left ventricle. As the management of LV thrombus is radically different from other malignant or nonmalignant mass, it is extremely important to differentiate the cause of LV mass. Echocardiography is the first-line imaging modality of choice for the evaluation of intracardiac mass.[6] Unusual location of thrombus as in our case creates diagnostic confusion which warrants further imaging assistance in the form of nucleotide scan or MRI. Cardiac MRI with contrast has significant better accuracy than transthoracic echocardiography and transesophageal echocardiography for the diagnosis of LV thrombus.[7],[8] Contrast echo or cardiac MRI should be considered if local resources are available in case of diagnostic confusion. Immediately after contrast administration, the homogeneous, strong enhancement of the LV cavity allows easy detection of abnormal intraventricular structures. Surgical removal is generally recommended for mobile thrombi due to a significant increase in embolization risk. However, deterioration of LV function, introduction of ventricular arrhythmia, and potential dissection of the left ventricle are all serious complications related to surgery.[9] Immediate postoperative mortality in the most series ranges from 0% to 7.5%.[10] Oral anticoagulant is another alternative treatment option for recent thrombus. In our case, after confirming the diagnosis of thrombus with multimodality imaging, we put the patient on anticoagulation. Thrombus was resolved completely on follow-up echocardiographic evaluation. Our case is unique, as the presentation of clot was at a very unusual location, only a few such cases have been reported in literature. With the help of multimodality imaging, we were able to successfully manage the case conservatively with oral anticoagulation.
Conclusion
Our case is unique, as the presentation of clot was at a very unusual location, only a few such cases have been reported in literature. With the help of multimodality imaging, we were able to successfully manage the case conservatively with oral anticoagulation.
Acknowledgment
We acknowledge Preeti Gahlan and Subrahmanya Murti V for their technical support.
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