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Free-floating left ventricular thrombus after rapid improvement of cardiac function related to mechanical hemodynamic support.

ABSTRACT: The incidence of acute complications is high in patients presenting late with acute myocardial infarction (AMI). We describe the case of a patient who presented late with anterior AMI that was complicated by left ventricular (LV) thrombus and electrical storm (ES). Temporary right ventricular pacing suppressed ES under extracorporeal membrane oxygenation support but reduced cardiac function. Immediately after returning to sinus rhythm (i.e. increase in cardiac function), free-floating LV thrombus was detected by echocardiography, resulting in cerebral embolism. Rapid improvement in cardiac function related to mechanical hemodynamic support may become a trigger for embolization in patients with LV thrombus. <Learning objective: Patients presenting late with acute myocardial infarction have a high incidence of complications. In patients with severe left ventricular (LV) dysfunction who require venoarterial extracorporeal membrane oxygenation, right ventricular (RV) pacing can advocate cardiac dysfunction with insufficient aortic valve opening. When patients have LV thrombus in this situation, rapid improvement in cardiac function by the interruption of RV pacing can dislodge LV thrombus, leading to systematic embolism.>.

SUBMITTER: Kikuchi S

PROVIDER: S-EPMC7283294 | biostudies-literature | 2020 Jun

REPOSITORIES: biostudies-literature

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Free-floating left ventricular thrombus after rapid improvement of cardiac function related to mechanical hemodynamic support.

Kikuchi Shinnosuke S Hibi Kiyoshi K Tamura Kouichi K Kimura Kazuo K

Journal of cardiology cases 20200318 6

The incidence of acute complications is high in patients presenting late with acute myocardial infarction (AMI). We describe the case of a patient who presented late with anterior AMI that was complicated by left ventricular (LV) thrombus and electrical storm (ES). Temporary right ventricular pacing suppressed ES under extracorporeal membrane oxygenation support but reduced cardiac function. Immediately after returning to sinus rhythm (i.e. increase in cardiac function), free-floating LV thrombu ...[more]

PMID: 32547660

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Project description:Left ventricular thrombus (LVT) is a serious complication of acute myocardial infarction (MI) and also non-ischemic cardiomyopathies. We performed a narrative literature review, manual-search of reference lists of included articles and relevant reviews. Our literature review indicates that the incidence of LVT following acute MI has decreased, probably due to improvement in patient care as a result of better and earlier reperfusion techniques. Predictors of LVT include anterior MI, involvement of left ventricular (LV) apex (regardless of the coronary territory affected), LV akinesis or dyskinesis, reduced LV ejection fraction (LVEF), severe diastolic dysfunction and large infarct size. LVT is associated with increased risk of systemic embolism, stroke, cardiovascular events and death, and there is evidence that anticoagulant therapy for at least 3 months can reduce the risk of these events. Cardiac magnetic resonance (CMR) has the highest diagnostic accuracy for LVT, followed by echocardiography with the use of echocardiographic contrast agents (ECAs). Although current guidelines suggest use of vitamin K antagonist (VKA) for a minimum of 3 to 6 months, there is growing evidence of the benefits of direct acting oral anticoagulants in treatment of LVT. Embolic events appear to occur even after resolution of LVT suggesting that anticoagulant therapy needs to be considered for a longer period in some cases. Recommendations for the use of triple therapy in the presence of the LVT are mostly based on extrapolation from outcome data in patients with atrial fibrillation (AF) and MI. We conclude that the presence of LVT is more likely in patients with anterior ST-segment elevation MI (STEMI) (involving the apex) and reduced ejection fraction (EF). LVT should be considered a marker of increased long-term thrombotic risk that may persist even after thrombus resolution. Ongoing clinical trials are expected to elucidate the best management strategies for patients with LVT.

Dataset Information

Free-floating left ventricular thrombus after rapid improvement of cardiac function related to mechanical hemodynamic support.

Publications

Free-floating left ventricular thrombus after rapid improvement of cardiac function related to mechanical hemodynamic support.

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