Massive Left Ventricular Thrombus
Shiv Sab MD, Sanket Dhruva MD, Jeffrey Paulsen MD, Sandhya Venugopal MD, Ezra
Amsterdam MD
University of California, Davis Medical Center, Sacramento, CA
INTRODUCTION
CLINCAL COURSE
•Left ventricular (LV) thrombus may form after a myocardial infarction or in
severe systolic dysfunction. The genesis is primarily dependent on stasis due
to poor contractility in a regional area. [3]
• The patient was admitted to the cardiology service for further evaluation of syncope.
• Given his confusion, the patient was sent for MRI/MRA brain, which showed an acute left posterior
cerebral distribution infarct. Its appearance was most consistent with a cardio-embolic etiology given
the presence of LV thrombus on echocardiography.
•LV thrombi carry a risk of embolization of 1-3% [3]
•Current treatment guidelines have not reached a consensus over optimal
management of large LV thrombi
•Initial management included permissive hypertension and an infusion of intravenous heparin, with a
plan to bridge to a therapeutic international normalized ratio (INR) with warfarin.
LEARNING OBJECTIVES
•Cardiothoracic surgery was consulted for possible thrombectomy. However, because of the patient’s
severe LV dysfunction, the risk of surgery was considered excessive and medical therapy was
continued.
We present a case of a massive LV thrombus and highlight the dilemma of
optimal treatment and the potential for serious adverse sequelae
CASE PRESENTATION
HPI:
A 53-year-old man with history of non-ischemic cardiomyopathy (with prior
LVEF 20%), hypertension, diabetes mellitus type 2 and mild chronic renal
insufficiency presented to the emergency department (ED) after transient loss
of consciousness leading to a motor vehicle accident. On presentation, he
complained of peripheral vision loss and mild confusion; he denied
headache, chest pain, shortness of breath, palpitations, nausea, vomiting, and
focal weakness.
FIGURE 1: Apical 2 chamber view by
transthoracic echocardiogram revealing a
5.0 cm x 2.5 cm thrombus (arrow) in the
left ventricle.
FIGURE 2: Resolution of the LV thrombus
after embolization.
•The patient remained stable until hospital day #14, when he was found to have acute right-sided
weakness and loss of sensation.
DISCUSSION
•Repeat MRI brain revealed acute-appearing progression of PCA infarction, with frank occlusion of
that vessel (Figure 4).
•Repeat TTE no longer demonstrated an LV thrombus (figure 2).
•On hospital day #18, the patient had pulselessness of his right lower extremity. Arterial duplex
ultrasound and MRI showed acute thromboembolic occlusion of the popliteal, anterior tibial,
tibioperoneal and peroneal arteries (Figure 3).
The patient ultimately underwent right lower extremity above the knee amputation for critical limb
ischemia. He was discharged to an inpatient rehabilitation facility after a prolonged hospitalization
complicated by heart failure exacerbation, seizures, and sustained altered mental status requiring
conservatorship.
PHYSICAL EXAM:
VS: T:96.4 HR: 98 BP: 214/150 RR: 18 SpO2: 97% on ambient air
DISCUSSION
General: Alert and oriented to person but not place or time
HEENT: Pupils equal round reactive bilaterally. JVP 12 cm H20
CV: S1/S2 regular rate/rhythm. PMI laterally displaced to the axillary line
Pulm: clear air entry bilaterally
Abd: soft nt/nd +BS
Extremities: warm ,well-perfused with 2+ pitting edema
Neuro: strength, sensation, and reflexes intact bilaterally. R sided
dysdiadochokinesia
STUDIES:
• Laboratory –mild hyponatremia and mild renal insufficiency
• Electrocardiogram – Sinus tachycardia with rate 110 bpm; left anterior
fascicular block, and evidence for prior inferior infarct.
FIGURE 4: DWI MRI showing an acute
infarction of the left posterior cerebral
artery. (arrow)
FIGURE 3: T2 MRI of right lower
extremity showing an acute infarction of the
popliteal, anterior tibial, tibioperoneal, and
peroneal arteries from systemic
embolization. (arrow)
•Therapeutic anticoagulation is the standard treatment for thromboembolic disease and is
suggested by the 2009 American College of Cardiology Foundation/American Heart
Association guidelines for LV thrombus that has embolized [1]
•However, guidelines regarding the management of LV thrombus are not definitive for
cases in which the mass is >5.0 cm; but it is maintained that with therapeutic
anticoagulation, the majority of LV thrombi will resolve without evidence of systemic
embolization [1].
•Surgical thrombectomy is indicated in patients with recurrent emboli despite therapeutic
anticoagulation and in patients with additional indications for cardiac surgery
•Despite anticoagulation at a therapeutic INR, our patient’s thrombus embolized multiple
times
•This case supports the proclivity of massive, mobile thrombus to embolize and indicates
the limitations of current management for this clinical challenge
References
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Dimensional Echocardiography. Circulation 1984;70:588-598.
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