Left ventricular thrombus in the setting of anterior acute myocardial infarction.

Creado por team@ekgdx.com el 7 de Enero de 2024

Today's article is about a case with left ventricular thrombus in the setting of anterior acute myocardial infarction.

The occurrence of left ventricular (LV) thrombus after acute myocardial infarction has significantly decreased in recent years due to advancements in reperfusion and antithrombotic treatments. However, despite this decline, embolic events continue to be a concerning complication of LV thrombus, requiring systemic anticoagulation. Mechanistically, the development of LV thrombus is influenced by Virchow's triad, which includes endothelial injury from myocardial infarction, blood stasis from LV dysfunction, and hypercoagulability triggered by inflammation. Each of these elements represents potential targets for therapeutic intervention. 

Let’s talk about the case (see my previous case report here).

A 59-year-old male patient with multiple risk factors for coronary artery disease (CAD) comes to the clinic complaining of chest pain since last night. Upon arrival, patient looks pale and presents shortness of breath.

 

This EKG was performed in triage. What do you think?

 

Here the EKG labeled with my concern. Note the abnormal ST segment elevation in leads I, II, III, aVF, V3-V6. 

 

Echocardiogram at bedside was performed and showed a concerning LV thrombus and the patient was rushed to the cath lab. 

 

The left heart cath showed 90% stenosis of the LAD that was successfully revascularized with a drug eluting stent. The RCA has mild luminal irregularities without any obstructive disease. AV not crossed given the concerns for LV thrombus on bedside echo.

 

Note: these types of cases are very complex to handle. Below you can see a proposed algorithm for the diagnosis and management of LV thrombi following acute myocardial infarction. 

 

Credit image: J Am Coll Cardiol. 2022 Mar, 79 (10) 1010–1022.

 

Central illustration

 

Learning points

  • LV thrombus is most often seen in patients with large anterior acute myocardial infarction when the left anterior descending coronary artery (LAD) is the culprit and can occur even in absence of aneurysm (Weinsaft, J. W et al 2016). 
  • The treatment of individuals with left ventricular mural thrombus following acute myocardial infarction is challenging, given the scarcity of conclusive evidence from randomized trials.
  • Early diagnosis of LV thrombus is critical to avoid thromboembolism.
  • Perform a bedside echocardiogram in all cases of acute myocardial infarction, particularly focusing on infarctions affecting the anterior wall.
  • Approaches addressing Virchow's triad, aiming to reduce myocardial injury, prevent left ventricular remodeling (stasis), and manage inflammation, are anticipated to be foundational in preventing and managing left ventricular thrombus in the foreseeable future.

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References

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Thanks for reading this teaching case.

Dr. Roig

Left ventricular thrombus acute myocardial infarction.