An Unusual Case of a Large Left Ventricle Thrombus Presenting as NSTEMI




Ahmed, Shahzad
Jipescu, Daniel
Khan, Ahsan
Chou, Mark
Johnson, Douglas


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Background: Although not common, the Left Ventricle (LV) thrombus can occur within 24 hours post myocardial infarction. Visser et al., showed that about 90% of thrombi are formed at maximum of 2 weeks after the event but can occur as late as 3 months to one year. Thrombus occurs most often with ST-elevation myocardial infarction and it seems to disappear more often in patients with apical akinesia than those with apical aneurysm or dyskinesia. Here we present a case of a large free flowing LV thrombus presenting as an NSTEMI from embolization. Case Report: A 56-year-old Hispanic male with PMHx significant for prosthetic aortic valve replacement, permanent pacemaker, paroxysmal A-fib on coumadin, bilateral femoral arteries thrombectomy, heart failure, HTN was brought in by ambulance for retrosternal chest pain (CP) radiating to the left arm. CP was associated with SOB, nausea, headache. Patient underwent cholecystectomy and appendectomy 2 weeks ago. His family reports that Coumadin was stopped during the admission process and was not restarted. The rest of the review of systems was noncontributory except for recent lower extremity edema. Physical exam was significant for lower extremity edema and positional SOB that was worse with the patient lying down and improved with him sitting up in a very specific position. Cardiac exam was WNL, no S3, S4 noted. During the initial work-up it was noted: BUN is 54, creatinine 1.51. Troponin 0.11. EKG with paced rhythm. The patient was diagnosed with acute kidney injury and NSTEMI. Due to persistent chest pain he was taken to the catheterization lab where he was found to have occluded, PDA and PLV and 85% occlusion of PDA branch with clot, underwent successful manual thrombectomy and PTCA. Due to the clot burden cardiology suspected possible origin of thrombus to be of intracardiac origin. Echocardiogram was ordered an extremely impressive echodense mass was noted. This was 5x5 centimeters with a remarkable and dramatic movement in the left ventricle. It was mostly considered to be a large mural clot. Right and left ventricular function was severely impaired. Cardiothoracic surgery and Interventional Radiology were unable to assist with removing the clot. Palliative services assisted with placing the patient on hospice. Discussion/Conclusion: Would like to have the opportunity to share this case with our colleagues due to the staggering echo imaging, the impressive positional SOB that show one more time that a good history and a physical exam are very important for reaching the appropriate diagnosis, and last but not the least due to the extremely difficult treatment option and ethical challenges in patient like this with severe comorbidities.