Case report
Noncompaction and embolic myocardial infarction: The importance of oral anticoagulation
Não-compactação e enfarte do miocárdio embólico: a importância da anticoagulação oral
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Camillo Hospital, Rome, Italy" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Interventional Cardiology, S. Camillo Hospital, Rome, Italy" "etiqueta" => "b" "identificador" => "aff0010" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "pt" => array:1 [ "titulo" => "Não-compactação e enfarte do miocárdio embólico: a importância da anticoagulação oral" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 640 "Ancho" => 1901 "Tamanyo" => 147928 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Left coronary angiogram showing a thrombotic total occlusion in the mid segment of the left anterior descending artery (LAD); (B) left coronary angiogram following percutaneous coronary intervention showing no significant stenoses; (C) thrombotic material retrieved from the LAD by thrombus aspiration.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Case report</span><p id="par0005" class="elsevierStylePara elsevierViewall">Isolated left ventricular noncompaction (LVNC) is a form of cardiomyopathy resulting from persistence of fetal trabeculations and intertrabecular recesses within ventricular myocardium. The clinical features associated with LVNC consist of left ventricular (LV) systolic dysfunction, arrhythmias, and thromboembolic events. We report the case of a 67-year-old woman admitted to the emergency department with acute aphasia, dyspnea, and peripheral edema associated with recent-onset paroxysmal atrial fibrillation (AF) with high ventricular rate. After anticoagulation with unfractionated heparin (UFH), she was converted to stable sinus rhythm with intravenous (IV) amiodarone. She was then admitted to the intensive coronary care unit (ICCU) and treated with IV inotropes and diuretics, resulting in prompt recovery from aphasia and improvement in congestion. The echocardiogram showed a markedly dilated left ventricle with hypertrabeculation of the apex and of the inferior-inferolateral segments (noncompacted/compacted ratio 2:1), severely reduced ejection fraction (EF) (22%), and an apical thrombus. No significant carotid artery disease was found on Doppler echocardiography. She underwent implantation of an implantable cardioverter-defibrillator and was discharged in NYHA class II, under standard heart failure therapy including oral anticoagulation (OAC), with no evidence of thrombosis (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>). Twelve months later, due to a major depressive episode, the patient failed to attend the scheduled heart failure clinic (HFC) follow-up and discontinued OAC. Due to recurrent dyspnea and fatigue she presented to the HFC, where an echocardiogram showed a massive LV thrombosis (<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>), so she was admitted to the ICCU and IV UFH was started. After two days the patient complained of chest pain; as the ECG showed marked ST segment elevation in V3-V6 she was referred to the catheterization lab. Coronary angiography revealed a thrombotic occlusion of the mid segment of the left anterior descending artery (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>A); the clot was aspirated and no significant coronary artery disease (CAD) was found (<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>B and C). A marked increase in plasma troponin I was observed, confirming the diagnosis of acute embolic myocardial infarction (MI). Her EF fell to 15% and after two days she became hypotensive despite intra-aortic balloon pump and inotropic support, with cardiogenic shock and acute kidney failure. She was considered for a left ventricular assist device, but sepsis and multiorgan failure occurred, and death followed 25 days later.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Discussion</span><p id="par0010" class="elsevierStylePara elsevierViewall">LVNC is associated with HF, arrhythmias and embolism. Cardioembolic events are not uncommon, as trabecular recesses and depressed systolic function predispose to thrombosis, but presentation as an acute coronary syndrome (ACS) is rather unexpected.<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">1</span></a> Previous observations suggested that in patients with reported myocardial infarction and LVNC, ischemia is mainly related to CAD and does not appear to be relevant to LVNC.<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">2</span></a> However, in the small number of reported cases of ACS in LVNC patients with no evidence of coronary stenosis or LV thrombosis, myocardial infarction was described as a consequence of microvascular dysfunction, as LVNC patients exhibit decreased coronary flow reserve in both compacted and noncompacted LV segments<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">3</span></a> and subendocardial perfusion defects despite normal coronary arteries.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> In a few of them embolism from thrombosis of the LV chamber was suggested, but with no reported evidence of intracavitary thrombus.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> In our patient, significant angiographic CAD was absent and the evidence of LV thrombosis itself strongly supports embolism as the most likely etiology. Although MI as an embolic complication is relatively infrequent, stroke and/or embolism occur in at least 15% of LVNC patients, mostly in those with advanced HF and AF,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> which implies that OAC is worth starting in the presence of predisposing factors. Nevertheless, in the absence of such conditions, cardioembolic events are rare, and stroke and/or embolism may also have an atherosclerotic cause. Hence, the embolic risk in LVNC patients with systolic dysfunction in sinus rhythm is largely unknown and OAC is mainly an individual therapeutic choice, mandatory in those with evidence of LV thrombosis, or a prudent option in primary prevention for those at the highest risk of embolization.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> In our case OAC was initially prescribed because of a previous transient ischemic attack with LV thrombosis, and paroxysmal AF.</p><p id="par0015" class="elsevierStylePara elsevierViewall">In conclusion, this case suggests that, although infrequent, ACS is a possible manifestation of LVNC-related embolism, and so an embolic etiology should be kept in mind in differential diagnosis between atherosclerosis in LVNC patients presenting with MI. Careful attention should be paid to embolic risk stratification and the need for OAC in such patients.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Ethical disclosures</span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Protection of human and animal subjects</span><p id="par0020" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Confidentiality of data</span><p id="par0025" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Right to privacy and informed consent</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article.</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Conflicts of interest</span><p id="par0035" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:9 [ 0 => array:3 [ "identificador" => "xres538935" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec558603" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres538934" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec558604" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 6 => array:3 [ "identificador" => "sec0015" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0020" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0025" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0030" "titulo" => "Right to privacy and informed consent" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Conflicts of interest" ] 8 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2014-10-05" "fechaAceptado" => "2015-01-02" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec558603" "palabras" => array:4 [ 0 => "Left ventricular noncompaction" 1 => "Embolism" 2 => "Heart failure" 3 => "Myocardial infarction" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec558604" "palabras" => array:4 [ 0 => "Não compactação ventricular esquerda" 1 => "Embolia" 2 => "Insuficiência cardíaca" 3 => "Enfarte do miocárdio" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Left ventricular noncompaction (LVNC) is characterized by left ventricular (LV) hypertrabeculations and is associated with heart failure, arrhythmias and embolism. We report the case of a 67-year-old LVNC patient, under oral anticoagulation (OAC) therapy for apical thrombosis. After she discontinued OAC, the thrombus involved almost the whole of the left ventricle; in a few months her condition worsened, requiring hospitalization, and despite heparin infusion she experienced myocardial infarction (MI), caused by embolic occlusion of the left anterior descending artery. Although infrequent as a complication of LVNC, and usually attributable to microvascular dysfunction, in this case MI seems due to coronary thromboembolism from dislodged thrombotic material in the left ventricle.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A não compactação ventricular esquerda (NCVE) é caracterizada por hipertrabeculações ventriculares esquerdas (VE) e está associada à insuficiência cardíaca, arritmias e embolias. Divulgamos o caso de uma doente de 67 anos com NCVE e em terapêutica de anticoagulação oral (ACO) por trombose apical. Como descontinuou a anticoagulação oral o trombo envolveu quase todo o VE; em poucos meses a sua situação piorou necessitando internamento e – apesar da infusão com heparina – sofreu um enfarte do miocárdio (EM), causado por oclusão embólica da DAE. Embora seja pouco frequente tal como a complicação por NCVE e seja geralmente atribuível à disfunção microvascular, o EM parece ser, neste caso, devido ao tromboembolismo coronário a partir do trombo do VE.</p></span>" ] ] "multimedia" => array:3 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 681 "Ancho" => 2001 "Tamanyo" => 173852 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">(A) Apical 4-chamber view and (B) parasternal short-axis view of mid segments showing intertrabecular recesses filled with blood in the anterolateral segments.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 1212 "Ancho" => 1801 "Tamanyo" => 166489 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">(A) Parasternal short-axis view of the mid segments. Two-layered structure of the thickened myocardium, with deep trabecular recesses in inferior, inferolateral and anterolateral segments; (B) apical 5-chamber view showing a floating thrombotic mass; (C) parasternal short-axis view showing thrombotic masses in the basal and mid segments of the anterior wall of the left ventricle.</p>" ] ] 2 => array:7 [ "identificador" => "fig0015" "etiqueta" => "Figure 3" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr3.jpeg" "Alto" => 640 "Ancho" => 1901 "Tamanyo" => 147928 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Left coronary angiogram showing a thrombotic total occlusion in the mid segment of the left anterior descending artery (LAD); (B) left coronary angiogram following percutaneous coronary intervention showing no significant stenoses; (C) thrombotic material retrieved from the LAD by thrombus aspiration.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:7 [ 0 => array:3 [ "identificador" => "bib0040" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular non-compaction revisited: a distinct phenotype with genetic heterogeneity?" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "E. Oechslin" 1 => "R. Jenni" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehq508" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J" "fecha" => "2011" "volumen" => "32" "paginaInicial" => "1446" "paginaFinal" => "1456" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21285074" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0045" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Noncompaction of the myocardium in a patient with acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "E. Correia" 1 => "L.F. Santos" 2 => "B. 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Oechslin" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "J Am Coll Cardiol" "fecha" => "2002" "volumen" => "39" "paginaInicial" => "450" "paginaFinal" => "454" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/11823083" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0055" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "MRI of subendocardial perfusion deficits in isolated left ventricular noncompaction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "R. Soler" 1 => "E. Rodriguez" 2 => "L. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 3 | 2 | 5 |
| 2024 October | 29 | 31 | 60 |
| 2024 September | 37 | 25 | 62 |
| 2024 August | 38 | 33 | 71 |
| 2024 July | 44 | 26 | 70 |
| 2024 June | 34 | 22 | 56 |
| 2024 May | 41 | 22 | 63 |
| 2024 April | 35 | 28 | 63 |
| 2024 March | 32 | 20 | 52 |
| 2024 February | 33 | 14 | 47 |
| 2024 January | 25 | 20 | 45 |
| 2023 December | 32 | 28 | 60 |
| 2023 November | 39 | 21 | 60 |
| 2023 October | 43 | 12 | 55 |
| 2023 September | 35 | 20 | 55 |
| 2023 August | 29 | 21 | 50 |
| 2023 July | 34 | 8 | 42 |
| 2023 June | 27 | 11 | 38 |
| 2023 May | 44 | 25 | 69 |
| 2023 April | 22 | 2 | 24 |
| 2023 March | 23 | 21 | 44 |
| 2023 February | 27 | 24 | 51 |
| 2023 January | 26 | 16 | 42 |
| 2022 December | 40 | 31 | 71 |
| 2022 November | 38 | 26 | 64 |
| 2022 October | 19 | 12 | 31 |
| 2022 September | 18 | 28 | 46 |
| 2022 August | 42 | 33 | 75 |
| 2022 July | 31 | 27 | 58 |
| 2022 June | 25 | 16 | 41 |
| 2022 May | 21 | 42 | 63 |
| 2022 April | 23 | 20 | 43 |
| 2022 March | 26 | 30 | 56 |
| 2022 February | 25 | 23 | 48 |
| 2022 January | 16 | 21 | 37 |
| 2021 December | 27 | 26 | 53 |
| 2021 November | 25 | 32 | 57 |
| 2021 October | 32 | 37 | 69 |
| 2021 September | 24 | 33 | 57 |
| 2021 August | 28 | 32 | 60 |
| 2021 July | 17 | 24 | 41 |
| 2021 June | 7 | 16 | 23 |
| 2021 May | 35 | 27 | 62 |
| 2021 April | 31 | 35 | 66 |
| 2021 March | 46 | 29 | 75 |
| 2021 February | 80 | 10 | 90 |
| 2021 January | 23 | 9 | 32 |
| 2020 December | 33 | 9 | 42 |
| 2020 November | 20 | 9 | 29 |
| 2020 October | 14 | 10 | 24 |
| 2020 September | 43 | 10 | 53 |
| 2020 August | 28 | 11 | 39 |
| 2020 July | 38 | 8 | 46 |
| 2020 June | 26 | 12 | 38 |
| 2020 May | 45 | 5 | 50 |
| 2020 April | 39 | 21 | 60 |
| 2020 March | 33 | 16 | 49 |
| 2020 February | 52 | 24 | 76 |
| 2020 January | 31 | 9 | 40 |
| 2019 December | 29 | 13 | 42 |
| 2019 November | 34 | 8 | 42 |
| 2019 October | 49 | 7 | 56 |
| 2019 September | 21 | 6 | 27 |
| 2019 August | 27 | 6 | 33 |
| 2019 July | 31 | 15 | 46 |
| 2019 June | 22 | 8 | 30 |
| 2019 May | 39 | 6 | 45 |
| 2019 April | 32 | 17 | 49 |
| 2019 March | 52 | 11 | 63 |
| 2019 February | 110 | 9 | 119 |
| 2019 January | 88 | 13 | 101 |
| 2018 December | 137 | 9 | 146 |
| 2018 November | 139 | 11 | 150 |
| 2018 October | 216 | 16 | 232 |
| 2018 September | 52 | 8 | 60 |
| 2018 August | 45 | 10 | 55 |
| 2018 July | 26 | 8 | 34 |
| 2018 June | 35 | 6 | 41 |
| 2018 May | 32 | 12 | 44 |
| 2018 April | 44 | 9 | 53 |
| 2018 March | 44 | 8 | 52 |
| 2018 February | 59 | 2 | 61 |
| 2018 January | 43 | 8 | 51 |
| 2017 December | 74 | 4 | 78 |
| 2017 November | 51 | 11 | 62 |
| 2017 October | 33 | 20 | 53 |
| 2017 September | 28 | 10 | 38 |
| 2017 August | 36 | 39 | 75 |
| 2017 July | 21 | 15 | 36 |
| 2017 June | 30 | 19 | 49 |
| 2017 May | 42 | 17 | 59 |
| 2017 April | 28 | 9 | 37 |
| 2017 March | 29 | 14 | 43 |
| 2017 February | 40 | 7 | 47 |
| 2017 January | 41 | 7 | 48 |
| 2016 December | 29 | 8 | 37 |
| 2016 November | 26 | 6 | 32 |
| 2016 October | 21 | 3 | 24 |
| 2016 September | 36 | 4 | 40 |
| 2016 August | 9 | 1 | 10 |
| 2016 July | 11 | 10 | 21 |
| 2016 June | 14 | 5 | 19 |
| 2016 May | 18 | 10 | 28 |
| 2016 April | 14 | 8 | 22 |
| 2016 March | 17 | 19 | 36 |
| 2016 February | 33 | 30 | 63 |
| 2016 January | 31 | 24 | 55 |
| 2015 December | 25 | 14 | 39 |
| 2015 November | 38 | 24 | 62 |
| 2015 October | 23 | 19 | 42 |
| 2015 September | 55 | 13 | 68 |
| 2015 August | 88 | 19 | 107 |
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