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Acute Lower-Limb Ischemia Due to Embolism of a Giant Left Ventricular Thrombus


 Department of Cardiology, Max Super Speciality Hospital, Patparganj, Delhi, India

Date of Submission06-Jun-2021
Date of Acceptance21-Jun-2021
Date of Web Publication23-Aug-2021

Correspondence Address:
Kapil Dev Mohindra,
Max Super Speciality Hospital, 108 A, IP Extension, Patparganj, Delhi - 110 092
India

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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jiae.jiae_23_21



How to cite this URL:
Mohindra KD, Kumar M. Acute Lower-Limb Ischemia Due to Embolism of a Giant Left Ventricular Thrombus. J Indian Acad Echocardiogr Cardiovasc Imaging [Epub ahead of print] [cited 2021 Oct 24]. Available from: https://www.jiaecho.org/preprintarticle.asp?id=324399


  Description Top


A 42-year-old man, a smoker, but without any other major cardiovascular risk factor or previous cardiac illness, presented with sudden-onset severe pain in the right lower limb for 1 day. Clinical examination revealed decreased mobility with loss of sensation in the right foot, along with absent distal right lower-limb pulses (posterior tibial and dorsalis pedis). An urgent lower-limb arterial Doppler scan was performed which revealed thrombotic occlusion of the right iliac, femoral, and popliteal arteries. Based on these findings, the patient was diagnosed as a case of acute thromboembolic occlusion of the right lower-limb arteries, requiring urgent limb salvage surgery.

Further evaluation was performed as part of the preoperative workup and also to elucidate the cause of embolism. A 12-lead electrocardiogram (ECG) was done which showed normal sinus rhythm with QS pattern in the precordial leads V1–V4, suggestive of old anterior wall myocardial infarction (MI) [Figure 1]a. Cardiac enzymes (troponin I) were within normal limits. Transthoracic echocardiography [Figure 1]b and [Figure 1]c revealed dyskinetic left ventricular (LV) apex with LV ejection fraction of 45% by the modified Simpson's method. The valves were structurally normal. However, there was a giant, elongated, tubular echo-dense mass, attached to the LV apex and extending into the LV outflow tract and even crossing the aortic valve during systole. The mass was 7 cm long and 3 cm wide at the base and was occupying much of the LV volume. The echocardiographic appearance and the clinical presentation were highly suggestive of this mass to be a thrombus.
Figure 1: (a) Twelve-lead electrocardiogram of the patient showing normal sinus rhythm with QS pattern in the V1–V4 leads; (b and c) transthoracic echocardiography images showing a giant, tubular thrombus (arrowheads) extending from left ventricular apex to outflow tract and intermittently crossing the aortic valve

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The patient underwent urgent surgical embolectomy with Fogarty catheter through the common femoral artery. The procedure was successful, with restoration of the right lower-limb pulses, normalization of the skin temperature, and gradual recovery of the right foot movement. The patient was then advised coronary angiography followed by surgical removal of the LV thrombus and coronary revascularization, as required. However, he refused for any further invasive intervention and was eventually discharged on oral anticoagulant therapy.

LV thrombus formation is a well-recognized complication of MI, especially anterior wall MI.[1],[2] LV thrombosis is also known to occur in other conditions that result in LV systolic dysfunction or those associated with hypercoagulable state.[3],[4] Apex is the most common site for LV thrombus formation, and the thrombi can be of various sizes. However, it is extremely uncommon to find such large thrombi extending from LV apex to the aortic valve and beyond.[5],[6],[7] Ours was thus a unique case. Although he did not have any history suggestive of MI in the past, the ECG and echocardiography were virtually diagnostic of old anterior wall MI.

Declaration of patient consent

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

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
McCarthy CP, Vaduganathan M, McCarthy KJ, Januzzi JL Jr., Bhatt DL, McEvoy JW. Left ventricular thrombus after acute myocardial infarction: screening, prevention, and treatment. JAMA Cardiol 2018;3:642-9.  Back to cited text no. 1
    
2.
Phan J, Nguyen T, French J, Moses D, Schlaphoff G, Lo S, et al. Incidence and predictors of left ventricular thrombus formation following acute ST-segment elevation myocardial infarction: A serial cardiac MRI study. Int J Cardiol Heart Vasc 2019;24:100395.  Back to cited text no. 2
    
3.
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. 3
    
4.
Grewal HK, Bansal M, Garg A, Kasliwal RR, Bhan A, Gautam D. Left ventricular thrombus and cardioembolic stroke in a patient with ulcerative colitis: A case report. Saudi J Med Med Sci 2021;9:67-70.  Back to cited text no. 4
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5.
Keskin K, Yıldız SS, Sığırcı S, Çetin Ş, Kılıçkesmez K. Giant left ventricular thrombus extending into the left ventricular outflow tract. Turk Kardiyol Dern Ars 2015;43:751.  Back to cited text no. 5
    
6.
Gupta S, Kahn RA. Image in clinical medicine. Left ventricular thrombus. N Engl J Med 2002;346:e5.  Back to cited text no. 6
    
7.
Moore PA, Segar DS. Twenty-five-year-old man with a giant left ventricular mass. J Am Soc Echocardiogr 2006;19:8.e7-8.  Back to cited text no. 7
    


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