Late development of intraventricular thrombosis

Barragán-Acea, Antonio; Harriague-Cáceres, Claudia; Padrón-Encalada, Remigio

doi:10.1016/j.medcle.2020.05.061

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It is more likely in patients with late revascularisation and especially in the case of previous infarcts that have resulted in apical contractile dysfunction.We report the case of a 23-year-old male who presented with acute coronary ischaemic syndrome with anterolateral elevation of the ST segment. The patient was included in the primary revascularization protocol. Catheterization began five hours after the onset of symptoms. Angiography showed a thrombotic occlusion of the proximal and middle segments of the anterior descending artery (TIMI 0), with normal flow in trunk, circumflex, and right coronary artery. After removal of the proximal thrombus, recovery of one flow (TIMI II) was achieved, with thrombosis persisting in the middle and distal segments of the vessel. Abciximab 0.25 mg/kg intracoronary bolus was administered. After which a 2.5 × 26 mm Orsiro drug-eluting stent was implanted in the proximal segment of the anterior descending artery and a 4.5/15 mm zotarolimus-eluting Resolute Onyx stent overlapped with the previous one. Recovery of proximal flow was achieved, although distal thrombosis persisted.Echocardiograms were performed according to clinical practice guidelines<a class="elsevierStyleCrossRef" href="#bib0005">1</a> on admission, at discharge, at six and 12 months. Intracavitary thrombosis was not observed in any of these studies. The study carried out before discharge revealed a contractility dysfunction, anterior and apical hypokinesis with mild global systolic dysfunction and ejection fraction of 50%.Blood tests showed a troponin I peak of 87 ng/mL; GOT 56 U/L, GPT 92 U/L, LDL was 102 mg/dL. Toxic metabolite testing during hospitalisation was negative. A coagulation study showed a free protein S deficiency due to a C677T MTHFR mutation, which did not require treatment with anticoagulation.The patient was discharged with acetylsalicylic acid 100 mg per day; ticagrelor 90 mg twice a day; bisoprolol 2.5 mg daily; ramipril 2.5 mg daily and atorvastatin 10 mg daily.An echocardiographic study carried out 18 months after the infarction revealed a large intraventricular thrombus at the apex of the left ventricle. The baseline study was completed with the use of contrast, which ruled out artifacts such as false apical tendons. After confirming the presence of an intraventricular thrombus, oral anticoagulation was indicated.With regard to this case, we would like to make some considerations that we believe are important to highlight for publication.Although the clinical guidelines for the treatment of heart attack<a class="elsevierStyleCrossRef" href="#bib0005">1</a> recommend, with a level of evidence II-b, preventive anticoagulation in anterior infarcts with severe contractile dysfunction, this strategy has been questioned due to excess bleeding without a clear benefit in preventing thrombus formation.<a class="elsevierStyleCrossRef" href="#bib0010">2</a> Although 5–7% of patients with infarction develop intraventricular thrombi, most form within the first 24 h and 90% are formed within the first two weeks. These thrombi resolve in 88% of patients within three and six months.<a class="elsevierStyleCrossRef" href="#bib0015">3</a> Although their presence is always a matter of concern for clinicians, given the considerable embolic risk they represent.<a class="elsevierStyleCrossRef" href="#bib0020">4</a>Patients with protein S or protein C deficiency without antithrombin deficiency, especially younger ones, have a high risk of thromboembolism, but its relationship with the formation of intraventricular thrombi is not clear.<a class="elsevierStyleCrossRef" href="#bib0025">5</a>In our case, intraventricular thrombus was not observed in the ultrasound studies recommended in the guidelines, performed at 48 h, six days, or 12 months after the infarction.The thrombus was observed at 18 months, six months after the discontinuation of dual antiplatelet therapy with ticagrelor.The uniqueness of the case lies in the late onset of intraventricular thrombosis. An unforeseen complication even with the correct completion of the clinical practice guidelines.We therefore believe that patients with a higher thrombotic risk, as was the case here, should be monitored more closely than what is recommended in the guidelines, because of possible late thrombus formation, even in cases when ultrasound contrast is used.FundingThis article has not received any type of funding.Conflict of interestsThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Funding" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Conflict of interests" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Barragán-Acea A, Harriague-Cáceres C, Padrón-Encalada R. Desarrollo tardío de trombo intraventricular. Med Clin (Barc). 2020. https://doi.org/10.1016/j.medcli.2020.05.050" ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:5 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation: The Task Force for the management of acute myocardial infarction in patients presenting with ST-segment elevation of the European Society of Cardiology (ESC)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B. Ibanez" 1 => "S. James" 2 => "S. Agewall" 3 => "M.J. Antunes" 4 => "C. Bucciarelli-Ducci" 5 => "H. Bueno" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/eurheartj/ehx393" "Revista" => array:6 [ "tituloSerie" => "Eur Heart J." "fecha" => "2018" "volumen" => "39" "paginaInicial" => "119" "paginaFinal" => "177" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28886621" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Incidence and predictors of left ventricular thrombus by cardiovascular magnetic resonance in acute ST-segment elevation myocardial infarction treated by primary percutaneous coronary intervention: a meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "H. Bulluck" 1 => "M.H.H. Chan" 2 => "V. Paradies" 3 => "R.L. Yellon" 4 => "H.H. Ho" 5 => "M.Y. Chan" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1186/s12968-018-0494-3" "Revista" => array:5 [ "tituloSerie" => "J Cardiovasc Magn Reson." "fecha" => "2018" "volumen" => "20" "paginaInicial" => "72" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30404623" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0015" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular thrombus after primary PCI for ST-elevation myocardial infarction: 1-year clinical outcomes" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "A.J. Moss" 1 => "A.S.V. Shah" 2 => "E.T. Zuling" 3 => "M. Freeman" 4 => "D.E. Newby" 5 => "P.D. Adamson" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjmed.2019.02.033" "Revista" => array:6 [ "tituloSerie" => "Am J Med." "fecha" => "2019" "volumen" => "132" "paginaInicial" => "964" "paginaFinal" => "969" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/30871923" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0020" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Left ventricular thrombus after acute myocardial infarction: screening, prevention, and treatment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "C.P. McCarthy" 1 => "M. Vaduganathan" 2 => "K.J. McCarthy" 3 => "J.L. Januzzi Jr" 4 => "D.L. Bhatt" 5 => "J.W. McEvoy" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jamacardio.2018.1086" "Revista" => array:6 [ "tituloSerie" => "JAMA Cardiol." 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"fecha" => "2014" "volumen" => "28" "paginaInicial" => "430" "paginaFinal" => "432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24011912" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673609610345" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23870206/0000015700000004/v2_202201010719/S2387020621003697/v2_202201010719/en/main.assets" "Apartado" => array:4 [ "identificador" => "43309" "tipo" => "SECCION" "en" => array:2 [ "titulo" => "Letters to the Editor" "idiomaDefecto" => true ] "idiomaDefecto" => "en" ] "PDF" => "https://static.elsevier.es/multimedia/23870206/0000015700000004/v2_202201010719/S2387020621003697/v2_202201010719/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2387020621003697?idApp=UINPBA00004N"]

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Vol. 157. Issue 4.

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