CARDIOVASCULAR JOURNAL OF AFRICA • Volume 34, No 1, January–April 2023 AFRICA 51 An unusually large left ventricular thrombus complicating anterior myocardial infarction: the value of multimodality imaging Lifa Dhlamini, Ruchika Meel, Mashudu Nethononda Abstract Since the emergence of revascularisation for the treatment of myocardial infarction (MI), the incidence of left ventricular thrombus (LVT) has been declining. However, despite this, it is independently associated with increased morbidity and mortality rates. The mainstay of treatment is vitamin K antagonists, although non-vitamin K antagonists have been shown to be effective. Imaging plays an important role in the surveillance of LVT subsequent to MI. Herein, we emphasise the utility of multimodality imaging of a case of anterior MI complicated by a large LVT, and detail its management. Keywords: left ventricular thrombus, cardiac magnetic resonance, echocardiography Submitted 1/9/21, accepted 1/2/22 Published online 8/12/22 Cardiovasc J Afr 2023; 34: 51–54 www.cvja.co.za DOI : 10.5830/CVJA-2022-007 Case report A 50-year-old male was in acute confusion due to severe diabetic ketoacidosis (DKA). He was haemodynamically stable with a regular, fast pulse rate of 110 beats/min, a blood pressure of 165/88 mmHg without pulmonary oedema, and adequate urine output. His random glucose level was 20 mmol/l, arterial blood pH was 7, with a base excess of –24. A routine electrocardiogram (ECG) obtained on admission (Fig. 1) showed features of anterior myocardial infarction (MI) confirmed by a raised high-sensitivity troponin level of 4 533 ng/l. A transthoracic echocardiogram (TTE) revealed akinetic anterior and apical segments with an overall left ventricular ejection fraction of 25%. Furthermore, there was a large, highly mobile left ventricular thrombus (LVT) (Fig. 2). An urgent non-contrast computed tomography (CT) of the brain, performed to exclude cerebrovascular accident, was normal. In addition to rapid-acting insulin and fluids for DKA, he was also treated with dual antiplatelet therapy (aspirin and clopidogrel), parenteral anticoagulation (enoxaparin) and high-dose statin in the coronary care unit. Within 24 to 48 hours, his mental state had improved and his biochemical abnormalities resolved. At day 10 post admission, two- (2D) and three-dimensional (3D) transoesophageal echocardiograms (TOE) were performed (Figs 3–5). It revealed a persistently large serpiginous LVT, located at the apical and mid-septum and extending into the left ventricular outflow tract (LVOT). An additional small thrombus was attached to the aorto-mitral curtain, just below the aortic valve. At day 14 post admission, the thrombus was significantly reduced in size and a diagnostic coronary catheterisation was cautiously performed, which demonstrated a totally occluded mid-left anterior descending artery with Rentrop 1 collateral supply (Fig. 6). As the patient was asymptomatic and stable, we opted to continue on optimal medical therapy and the patient was referred for viability studies with cardiac magnetic resonance imaging. At day 15 post admission, the patient was commenced on warfarin, over and above the dual antiplatelet therapy (triple therapy). A cardiac magnetic resonance (CMR) was performed (Fig. 7), which showed an anteroseptal transmural infarction and a small residual thrombus attached to the infarcted segments. At day 28 post admission, a repeat TTE showed complete resolution of the LVT. Discussion LVT is not an uncommon complication of acute ST-segment elevation myocardial infarction (STEMI), with an incidence of 3–15% in the post-thrombolytic era.1,2 Among the factors associated with LVT are left ventricular (LV) systolic dysfunction, incomplete revascularisation, a high SYNTAX score and an elevated D-dimer level.3 Other studies have demonstrated an association with factors such as heart failure, involvement of the left anterior descending artery, apical akinesia, presence of a LV aneurysm and elevated biomarker levels.2,4-6 Although most thrombi are located apically, approximately 11% are found in the septum and 3% in the inferior–posterior wall.7 TTE is frequently the initial imaging modality for the identification of LVT.8 Srichai et al. compared various imaging modalities in the detection of LVT in the setting of acute STEMI and demonstrated a sensitivity and specificity of 23 and 96% for TTE, 40 and 96% for TOE, and 88 and 99% for contrastenhanced CMR.9 However, contrast echocardiography has been shown to improve the sensitivity of LVT detection.9,10 Systemic embolisation is a dreaded complication of LVT, occurring in up to 16.3% of cases.11 It has also been shown that patients with LVT have increased major cardiovascular Division of Cardiology, Chris Hani Baragwanath Hospital and University of the Witwatersrand, Johannesburg, South Africa Lifa Dhlamini, MB ChB, FCP (SA), MMed, Cert Cardiology, l.dhlamini@yahoo.com Ruchika Meel, MB ChB, MMED, Cert Cardiology, PhD, FEACVI, Ruchikameel@gmail.com Mashudu Nethononda, MB ChB, MMed, DPhil (Oxford), FCP (SA), FESC, FSCMR
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