Case report
Intracardiac thrombus and Murphy's law: Reflections on a clinical dilemma
Trombos intracardíacos e a lei de Murphy: reflexão sobre um dilema clínico
Patrícia Rodrigues
, Maria João Sousa, Luísa Caiado, Sofia Cabral, Ana Meireles, Mário Santos, Paulo Palma, Severo Torres
Corresponding author
Cardiology Department, Centro Hospitalar do Porto, Porto, Portugal
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LA: left atrial; LV: left ventricular.</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">We present the case of a 49-year-old male, a smoker, with type 2 diabetes mellitus, hypertension, dyslipidemia, stage 3 renal failure and atrial fibrillation (AF). He had been recently diagnosed with probable tachycardiomyopathy, because of fluctuating degrees of left ventricular systolic dysfunction in the context of poorly controlled AF, in the absence of coronary artery disease.</p><p id="par0010" class="elsevierStylePara elsevierViewall">He was admitted with rapid AF and decompensated heart failure. In terms of AF treatment, he was taking bisoprolol, digoxin and warfarin, but his international normalized ratio was subtherapeutic.</p><p id="par0015" class="elsevierStylePara elsevierViewall">He was started on parenteral anticoagulation, but shortly after admission he developed left hemiparesis, pain in the lower limbs and abdominal pain.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The echocardiogram showed moderate left ventricular (LV) systolic impairment and a massive mobile thrombus in the LV apex (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>A and B) and another in the left atrium (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>C).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">Computed tomography confirmed multiple cerebral (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>D), splenic (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>E) and renal (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>F) infarcts, as well as an almost total occlusion of the infrarenal abdominal aorta (<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>G), distal to the origin of the inferior mesenteric artery.</p><p id="par0030" class="elsevierStylePara elsevierViewall">He was referred for emergent thrombectomy for removal of the aortic thrombus and continued anticoagulation, with favorable recovery.</p><p id="par0035" class="elsevierStylePara elsevierViewall">This is a catastrophic case of intracardiac thrombus with massive systemic emboli. It is a reminder of the dangerous association between atrial fibrillation and left ventricular systolic impairment, highlighting the importance of adequate anticoagulation in these patients.</p><p id="par0040" class="elsevierStylePara elsevierViewall">It also prompts reflection on the lack of treatment options available for patients when a large mobile protruding thrombus is already present and there is a substantial risk for systemic embolic phenomena, even with anticoagulation treatment. Surgical thrombectomy<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">1,2</span></a> may be considered, especially if there are recurrent emboli despite anticoagulation and if the thrombus remains large, but it also carries a very high risk.</p><p id="par0045" class="elsevierStylePara elsevierViewall">Some weeks later, another patient was admitted to our center with a history of ischemic heart disease and decompensated heart failure. She had a very large, apparently pedunculated and protruding LV thrombus. Medical and surgical treatment options were discussed, but her surgical risk was felt to be very high and she was started on anticoagulation, maintaining clinical stability. After a week, when she was about to be discharged, a transthoracic echocardiogram was repeated, which no longer showed any intracardiac thrombus. A few hours later, she suddenly died of a massive stroke.</p><p id="par0050" class="elsevierStylePara elsevierViewall">In conclusion, handling patients with a large intracardiac thrombus, particularly when located in the left cardiac chambers and clearly fresh, mobile and pedunculated, is often problematic. In these circumstances, to start anticoagulation and hope for the best feels quite insufficient.</p><p id="par0055" class="elsevierStylePara elsevierViewall">In the few observational studies available to date, 10–15% of patients with an LV thrombus (most of them after myocardial infarction) suffered a significant embolic event, especially in the first 3–4 months,<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">3</span></a> and anticoagulation was associated with a significant reduction in the occurrence of embolization.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">4,5</span></a> However, not all thrombi are the same. In particular, thrombus mobility and protrusion have been associated with a higher embolization risk, of approximately 60%.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">3,6</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">Since large, protruding, fresh thrombi are relatively rare, there are no studies that specifically address this problem. The few published case reports and observational studies of thrombus with these characteristics that were treated with a surgical approach showed successful results<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">2,7,8</span></a> and perhaps this option should be considered more often.</p><p id="par0065" class="elsevierStylePara elsevierViewall">Other options could also be explored, such as the development of a percutaneous device to temporarily contain the thrombus in the apex and facilitate aspiration, or some other option that increases the odds for a positive outcome.</p><p id="par0070" class="elsevierStylePara elsevierViewall">We hope that further research will be performed in this area and that it will be possible to offer a better treatment strategy for high-risk intracardiac thrombus.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Ethical disclosures</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Protection of human and animal subjects</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Confidentiality of data</span><p id="par0080" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Right to privacy and informed consent</span><p id="par0085" class="elsevierStylePara elsevierViewall">The authors have obtained the written informed consent of the patients or subjects mentioned in the article. The corresponding author is in possession of this document.</p></span></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Conflicts of interest</span><p id="par0090" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:8 [ 0 => array:3 [ "identificador" => "xres821811" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec818757" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres821810" "titulo" => "Resumo" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec818756" "titulo" => "Palavras-chave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0020" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0025" "titulo" => "Right to privacy and informed consent" ] ] ] 6 => array:2 [ "identificador" => "sec0030" "titulo" => "Conflicts of interest" ] 7 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2015-04-10" "fechaAceptado" => "2015-09-13" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec818757" "palabras" => array:4 [ 0 => "Left ventricular thrombus" 1 => "Embolization" 2 => "Anticoagulation" 3 => "Thrombectomy" ] ] ] "pt" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palavras-chave" "identificador" => "xpalclavsec818756" "palabras" => array:4 [ 0 => "Trombo do ventrículo esquerdo" 1 => "Embolização" 2 => "Anticoagulação" 3 => "Trombectomia" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">We discuss the case of a 49-year-old patient with left ventricular systolic dysfunction and a large, mobile and protruding apical thrombus. In spite of anticoagulation treatment, extensive and clearly defined systemic embolization occurred.</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">We discuss the current evidence on the treatment of intracardiac thrombus with high risk of systemic embolization and propose a tailored approach to avoid potential catastrophic consequences.</p></span>" ] "pt" => array:2 [ "titulo" => "Resumo" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Apresentamos o caso de um doente de 49 anos com disfunção sistólica ventricular esquerda e um trombo apical de grandes dimensões, móvel e com protrusão para a cavidade ventricular. Apesar do tratamento anticoagulante, ocorreram vários fenómenos de embolização sistémica, extensos e muito ilustrativos.</p><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Discutimos a evidência atual sobre o tratamento de trombos intracardíacos com alto risco de embolização sistémica e propomos uma reflexão sobre uma abordagem personalizada para evitar potenciais consequências catastróficas.</p></span>" ] ] "multimedia" => array:1 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 1941 "Ancho" => 2668 "Tamanyo" => 573578 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Transthoracic echocardiogram, apical 4-chamber view in diastole, showing apical LV thrombus; (B) transthoracic echocardiogram, apical 4-chamber view in systole, showing the thrombus protruding into the LV cavity; (C) transthoracic echocardiogram, apical 3-chamber view, showing the LV and LA thrombi; (D) cerebral computed tomography, displaying a large cerebral infarct; (E–G) abdominal computed tomography with contrast, showing splenic (E) and renal (F) infarcts and almost total occlusion of the infrarenal abdominal aorta (G). LA: left atrial; LV: left ventricular.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:8 [ 0 => array:3 [ "identificador" => "bib0045" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Urgent surgical removal of a rapidly growing left ventricular thrombus following acute myocardial infarction" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J. Leor" 1 => "O. Agranat" 2 => "R. 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Faber" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Heart Lung Vessel" "fecha" => "2014" "volumen" => "6" "paginaInicial" => "88" "paginaFinal" => "91" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25024990" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0080" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:3 [ 0 => "J.M. Lee" 1 => "J.J. Park" 2 => "H.W. 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| Year/Month | Html | Total | |
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| 2024 November | 8 | 7 | 15 |
| 2024 October | 65 | 29 | 94 |
| 2024 September | 86 | 23 | 109 |
| 2024 August | 58 | 30 | 88 |
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| 2023 November | 48 | 19 | 67 |
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| 2023 September | 48 | 21 | 69 |
| 2023 August | 35 | 23 | 58 |
| 2023 July | 41 | 8 | 49 |
| 2023 June | 34 | 10 | 44 |
| 2023 May | 67 | 19 | 86 |
| 2023 April | 34 | 6 | 40 |
| 2023 March | 58 | 25 | 83 |
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| 2020 December | 77 | 9 | 86 |
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| 2020 October | 61 | 16 | 77 |
| 2020 September | 99 | 14 | 113 |
| 2020 August | 71 | 13 | 84 |
| 2020 July | 71 | 9 | 80 |
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| 2020 February | 173 | 21 | 194 |
| 2020 January | 51 | 11 | 62 |
| 2019 December | 64 | 8 | 72 |
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| 2019 October | 47 | 10 | 57 |
| 2019 September | 74 | 9 | 83 |
| 2019 August | 49 | 3 | 52 |
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| 2019 June | 41 | 12 | 53 |
| 2019 May | 34 | 9 | 43 |
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| 2019 March | 74 | 12 | 86 |
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| 2018 December | 64 | 21 | 85 |
| 2018 November | 90 | 15 | 105 |
| 2018 October | 134 | 23 | 157 |
| 2018 September | 37 | 12 | 49 |
| 2018 August | 31 | 6 | 37 |
| 2018 July | 26 | 7 | 33 |
| 2018 June | 29 | 15 | 44 |
| 2018 May | 48 | 21 | 69 |
| 2018 April | 46 | 4 | 50 |
| 2018 March | 52 | 15 | 67 |
| 2018 February | 51 | 9 | 60 |
| 2018 January | 55 | 8 | 63 |
| 2017 December | 74 | 7 | 81 |
| 2017 November | 29 | 7 | 36 |
| 2017 October | 28 | 16 | 44 |
| 2017 September | 25 | 12 | 37 |
| 2017 August | 32 | 12 | 44 |
| 2017 July | 22 | 11 | 33 |
| 2017 June | 41 | 16 | 57 |
| 2017 May | 37 | 9 | 46 |
| 2017 April | 24 | 2 | 26 |
| 2017 March | 30 | 30 | 60 |
| 2017 February | 34 | 5 | 39 |
| 2017 January | 27 | 5 | 32 |
| 2016 December | 32 | 9 | 41 |
| 2016 November | 30 | 11 | 41 |
| 2016 October | 35 | 12 | 47 |
| 2016 September | 34 | 19 | 53 |
| 2016 August | 14 | 1 | 15 |
| 2016 July | 21 | 20 | 41 |
| 2016 June | 13 | 20 | 33 |
| 2016 May | 13 | 32 | 45 |
| 2016 April | 5 | 5 | 10 |
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