Not So Mural Thrombus

S. Coli
2006 Circulation  
A 64-year-old man with type 2 diabetes mellitus was admitted to our emergency department for a 12-hour history of waxing and waning chest pain. During the first hour of observation, he complained about a new episode of chest pain accompanied by ST elevation in leads V 2 and V 3 . The patient underwent emergency coronary angiography that showed 80% stenosis of the proximal left anterior descending artery with subocclusive thrombotic lesion of its middle segment and TIMI-1 distal flow. Contrast
more » ... ntriculography revealed left ventricular apical hypokinesia; primary angioplasty and stent implantation on the left anterior descending artery were performed. The patient was admitted to the coronary care unit and treated with ␤-blockers, captopril, unfractionated heparin, tirofiban, aspirin, and clopidogrel. Clinical, ECG, and biochemical signs of reperfusion were observed. Peak creatine phosphokinase was 696 U/L, with 35 g/L of the MB isoform. At the sixth day after admission, before the planned discharge, a standard second harmonic echocardiographic study (Sonos 5500 with S3 probe) revealed a hypokinetic apex with preserved wall thickness and a large mural thrombus (Movie I). Contrast echocardiography, performed to improve the definition of thrombus morphology (Figure 1 and Movie II), showed that the left ventricular thrombus was mobile and largely detached. This finding significantly increased the risk of embolism; therefore, the patient was not discharged, and full anticoagulation therapy with unfractionated heparin was started. The elevated potential embolic risk was confirmed after 5 days of therapy by a new contrast echocardiography study (Figure 2 and Movie III), which showed increased thrombus mobility. Two weeks after admission, echocardiography showed complete thrombus resolution. The patient was discharged on oral anticoagulants. Disclosures None. Figure 1. A second-generation contrast agent injection (perflutren protein type A microspheres, Optison), administered as an intravenous bolus (1.0 cm 3 ), showed that the left ventricular thrombus was only loosely attached to the apex by 2 slender peduncles and was much more mobile than in the standard study. Figure 2. Five days later, a second contrast echocardiography study showed the dissolution of 1 peduncle with higher mobility of the thrombus.
doi:10.1161/circulationaha.104.524876 pmid:16432058 fatcat:djgwz2sqrnc7bl5ratkffp2lea