Fibrinolytic treatment in left ventricular mobile thrombi with low ejection fraction: results and follow-up of seven cases

Complete Resolution of the Left Ventricular Pedunculated Thrombus with Tirofiban Infusion in a Patient with Severe Left Ventricular Dysfunction

A 28-year-old man was admitted with symptoms of heart failure. Echocardiography revealed severe left ventricular dysfunction, apical aneurysm, and a 40 × 11 mm sized mobile thrombus attached to apical septum with a narrow stalk. The patient had anterior myocardial infarction two years ago. Heparin infusion was started at 1000 IU/hour for 48 hours. There was no detected change on the size of the thrombus. Surgery recommended to the patient was refused by him because of the procedural risks. Tirofiban infusion was started. Repeat echocardiography showed significant reduction in thrombus size after 24 hours, and complete resolution of the thrombus after 48 hours. To our knowledge, this is the first case with left ventricular mobile thrombus treated successfully with tirofiban infusion.

Mobile left ventricular thrombus in left ventricular dysfunction: case report and review of literature

INTRODUCTION

Left ventricular (LV) thrombi carry a high risk of embolization. Therapeutic recommendations like treatment with low molecular heparin and intravenous unfractionated heparin (UFH), thrombolysis or surgical thrombectomy have failed to reach a consensus.

CASE DESCRIPTION

A 56-year-old female patient presented in cardiogenic shock to the emergency department. Echocardiography demonstrated a dilated LV with a severely depressed global systolic function and a large LV apical thrombus. Treatment with UFH was initiated as well as a treatment with catecholamines for stabilizing the patient's hemodynamic situation. On the follow-up echocardiographic examination, extensive free-floating parts of the thrombus could be documented. Given the high risk of embolization in a now hemodynamically stable situation, emergency surgical embolectomy was performed.

DISCUSSION

A conservative procedure might be useful for bridging till surgical treatment is available and/or the risk due to surgery is acceptable.

CONCLUSION

In absence of evidence-based guidelines for the treatment of LV thrombi, individualized management options concerning surgical, embolization and bleeding risk must be taken into account.

A black mobile mass: diagnosis and management

The diagnosis and treatment of left ventricular apical thrombi after myocardial infarction are still not well established. Fibrinolytic treatment, heparin treatment and surgical removal might be therapeutic options. We present the case of a 37 year old man who came into the Emergency department complaining of pleuritic chest pain. ECG revealed an evolving anterior wall infarction and transthoracic echocardiogram showed a big mobile thrombus in the ventricular apex. In order to confirm diagnosis and to differentiate other entities like pseudoaneurysm, contrast echocardiography and cardiac MRI with late gadolinium enhancement were performed and allowed a definitive diagnosis. Our patient was treated with intravenous heparin and then with oral anticoagulation. Two months later, echocardiogram showed an apical non-mobile and smaller thrombus.