European Journal of Echocardiography 2007 8(1):67-70; doi:10.1016/j.euje.2005.12.005
Copyright © 2005, The European Society of Cardiology
The vanishing vast ventricular thrombus
Lindsey Tilling* and
Harald Becher
Department of Cardiology, John Radcliffe Hospital, Headley Way, Headington, Oxford OX3 9DU, UK
Received 13 September 2005; received in revised form 24 November 2005; accepted after revision 4 December 2005.
* Corresponding author. Tel.: +0044 1865 741166. lindseytilling{at}hotmail.com
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Abstract
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A 54-year old man presented with multiple pulmonary emboli and
an incidental finding of a huge left ventricular thrombus. Transthoracic
echo images demonstrated a globally dilated heart with very
poor left ventricular function. It was elected to manage the
patient medically, and he was commenced on warfarin therapy,
resulting in completed resolution of the thrombus over 10 weeks.
No underlying cause was found and he did not experience any
further embolic events. This illustrates a rare case of a large
ventricular thrombus in a patient with no underlying risk factors.
Keywords: Left ventricular thrombus
A 54-year old man presented with a month's history of breathlessness and pleuritic chest pain. He had also noted a swollen, tender left leg after returning from Dubai one week previously. He was a smoker. Examination revealed a resting tachycardia and tachypnoea, evidence of congestive cardiac failure and reduced air entry in the right lung. His electrocardiogram showed sinus rhythm with a left ventricular strain pattern. Chest X-ray indicated consolidation at the right base, and a CT pulmonary angiogram revealed small pulmonary emboli in the left lingular and lower lobe arteries. An incidental finding of a large left ventricular mass was noted. Doppler ultrasound of the left leg was normal.
Echocardiography revealed a dilated left ventricle (end systolic diameter 46mm, end diastolic diameter 55mm) with severely compromised function, and a large apical thrombus (61x36mm) was seen (Fig. 1). Biatrial and biventricular dilatation and mild mitral and tricuspid regurgitation was noted. Pulmonary artery pressure was slightly elevated at 40mmHg.
We elected to treat the patient conservatively, and he was fully
anticoagulated with warfarin (target INR 3-4) and commenced
on treatment for heart failure (ramipril, bisoprolol, spironolactone,
and frusemide). After 10 weeks of warfarin the thrombus disappeared
and the left ventricle measured 36mm in systole, 46mm in diastole
(
Figs. 2–4
). Ventricular function improved, though remains
moderately impaired.
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Discussion
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Many conditions have been associated with predisposition to
ventricular thrombi. The commonest causes are post myocardial
infarct (mural thrombus)
1 and dilated cardiomyopathies.
2 Less
frequently myocarditis
3 and hypercoaguable states such as protein
S and C deficiency and antiphospholipid syndrome
4–6 have
been implicated. Ventricular thrombi have also been noted in
muscular dystrophies,
7 Behcet's disease,
8 HIV cardiomyopathy,
9 non-compaction cardiomyopathy
10 and blunt chest trauma.
11 It
is rare for a patient to present with a ventricular thrombus
in the absence of any underlying disease. Patients usually do
not have any symptoms, and ventricular thrombi are therefore
an incidental finding on echocardiography, which has a sensitivity
of almost 95 percent and a specificity of 90 percent.
12 The
main concern is that they will embolise, and for this reason
anticoagulation is mandated. Surgical thrombectomy may
be considered, particularly in the case of a large, protruding,
mobile thrombus, after failure of attempts at anticoagulation,
or in patients who are unable to take warfarin. It was
thought thrombectomy would put our patient at considerable risk
of complications, hence anticoagulation was used in the first
instance. We anticipate he will remain on warfarin lifelong.
Although we did not see echocardiographic evidence of right ventricular thrombus this is the most likely cause of the pulmonary emboli. No underlying cause for cardiomyopathy was found, nor was a thrombophilia detected. The patient's symptoms have resolved. He did not experience any further embolic events.
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References
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- Porter A., Kandalker H., Iakobishvili Z., Sagie A., Imbar S., Battler A., et al. Left ventricular mural thrombus after anterior ST-segment-elevation acute myocardial infarction in the era of aggressive reperfusion therapy – still a frequent complication. Coron Artery Dis (2005 Aug) 16(5):275–279.[CrossRef][Web of Science][Medline]
- Falk R.H., Foster E., Coats M.H. Ventricular thrombi and thromboembolism in dilated cardiomyopathy: a prospective follow-up study. Am Heart J (1992 Jan) 123(1):136–142.[CrossRef][Web of Science][Medline]
- Miyamoto K., Yasuda S., Noguchi T., Tanimoto T., Kakuchi H., Morii I., et al. Fulminant myocarditis causing severe left heart failure and massive thrombus formation following cardiac tamponade: a case report. J Cardiol (2005 Jul) 46(1):25–31.[Medline]
- Kim M.J., Hur S.H., Lee Y.S., Hyun D.W., Han S.W., Kim K.S., et al. Intracardiac multichamber thrombi in a patient with combined protein C and protein S deficiencies. Int J Cardiol (2005 Apr 28) 100(3):505–506.[CrossRef]
- Lim E., Wicks I., Roberts L.J. Intracardiac thrombosis complicating antiphospholipid antibody syndrome. Intern Med J (2004 Mar) 34(3):135–137.[CrossRef][Web of Science][Medline]
- Sallah S. Review. Right ventricle thrombosis and the hypercoagulable states. Clin Adv Hematol Oncol (2004 Mar) 2(3):18.
- Saito T., Yamamoto Y., Matsumura T., Nozaki S., Fujimura H., Shinno S. Coagulation system activated in Duchenne muscular dystrophy patients with cardiac dysfunction. Brain Dev (2005 Sep) 27(6):415–418. [Epub 2004 Dec 15].[CrossRef][Web of Science][Medline]
- Fekih M., Fennira S., Ghodbane L., Zaouali R.M. Intracardiac thrombosis: unusual complication of Behcet's disease. Tunis Med (2004 Aug) 82(8):785–790.[Medline]
- Peter A.A., Seecheran S. Images in cardiology: multiple ventricular thrombus in HIV cardiomyopathy. Heart (2005 Sep) 91(9):1248.[Free Full Text]
- Stollberger C., Finsterer J. Thrombi in left ventricular hypertrabeculation/noncompaction – review of the literature. Acta Cardiol (2004 Jun) 59(3):341–344.[CrossRef][Web of Science][Medline]
- Ruvolo G., Fattouch K., Speziale G., Macrina F., Tonelli E., Marino B. Left ventricular thrombosis after blunt chest trauma. J Cardiovasc Surg (Torino) (2001 Apr) 42(2):211–212.[Medline]
- Ascione L., Antonini-Canterin F., Macor F., Cervesato E., Chiarella F., Giannuzzi P., et al. Relation between early mitral regurgitation and left ventricular thrombus formation after acute myocardial infarction: results of the GISSI-3 echo substudy. Heart (Aug 2002) 88:131–136.[Abstract/Free Full Text]
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