Left ventricular thrombus formation after acute myocardial infarction

Meta-Analysis Comparing Direct Oral Anticoagulants to Vitamin K Antagonists for The Management of Left Ventricular Thrombus

Introduction: To compare vitamin K antagonists (VKAs) and direct oral anticoagulants (DOACs) treatment in patients with left ventricular (LV) thrombus. The primary outcome was stroke or systemic embolism (SSE). Secondary outcomes were thrombus resolution, bleeding, and death.Areas covered: Five observational studies were included (total n = 700; VKAs n = 480; DOACs n = 220). There was a trend toward less SSE with VKAs compared to DOACs (5.2% vs. 9%; odds ratio [OR] = 0.54, 95% confidence interval [CI] = 0.29-1.01, p = 0.05). No significant difference between VKAs and DOACs in rates of thrombus resolution (61.6% vs. 56.8%; OR = 1.00, 95% CI = 0.58-1.73, p = 0.99), bleeding (8.2% vs. 4.4%; OR = 1.62, 95% CI = 0.69-3.77, p = 0.27), or death (12.7% vs. 11.8%; OR = 1.09, 95% CI = 0.59-2.0, p = 0.79) was noted. In non-primary percutaneous coronary intervention setting, VKAs were associated with less SSE in prespecified analysis (5.2% vs.10.6%; OR = 0.48, 95% CI = 0.25-0.93, p = 0.03).Expert opinion: The current meta-analysis suggests a trend toward higher SSE with the use of DOACs compared to VKAs. Our recommendation is for VKAs to retain the preferred management of LV thrombus with cautious off-label use of DOACs.

Acute Ischemic Stroke Associated with Myocardial Infarction: Challenges and Management

Acute ischemic stroke (AIS) and acute myocardial infarction (AMI) may co-occur simultaneously or in close temporal succession, with occurrence of one ischemic vascular event increasing a patient's risk for the other. Both employ time-sensitive treatments, and both benefit from expert consultation. Patients are at increased risk of stroke for up to 3 months following AMI, and aggressive treatment of AMI, including use of reperfusion therapy, decreases the risk of AIS. For patients presenting with AIS in the setting of a recent MI, treatment with alteplase, an intravenous tissue plasminogen activator, can be given, provided anterior wall myocardial involvement has been carefully evaluated. It is important for clinicians to recognize that troponin elevations can occur in the setting of AIS as well as other clinical scenarios and that this may have implications for short- and long-term mortality.

Mesenteric ischemia following large left ventricular fibroid thrombosis due to myocardial infarction: A case report

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Left ventricular thrombosis (LVT) is commonly seen in patients with decreased systolic function.

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The patient was underwent mesenteric ischemia during hospitalization but the diagnosis of mesenteric ischemia prior to the patient's visit is not unlikely.

Introduction

Left ventricular thrombosis is a common complication of acute myocardial infarction, usually occurring after anterior ST-elevation myocardial infarction, akinesis, and extensive dyskinesia of the apex, anterolateral, or anteroseptal. In this article, we report a case of myocardial infarction with left ventricular thrombosis.

Case presentation

A 45-year-old man was referred to our hospital with complaints of severe epigastric pain, sweating, fever, and tachycardia. In laboratory tests, findings for triose phosphate isomerase enzyme were negative, but on electrocardiography, the Q wave in the V1 and V2 leads and the biphasic T wave in the V2, V3, and V4 leads were evident. In Akinesian echocardiography, apical segmentation with a large organic, mobile, pedunculated thrombosis measuring 1.7 × 1.9 cm² and an ejection fraction of 40% were reported. The patient then underwent emergency open cardiac surgery through a central sternotomy to remove the thrombosis.

Clinical discussion

The clinical manifestations of left ventricular thrombosis include cerebral thromboembolism and systemic distal embolization, which are dangerous despite surgery. The echocardiography revealed that the left ventricular keratosis had been surgically removed through ventriculotomy. The patient experienced mesenteric ischemia during hospitalization, and due to the initial presentation of severe abdominal pain, it is not uncommon for the patient to be diagnosed with mesenteric ischemia before referral. The patient had the following vital signs: SPO₂, 98%; BP, 96/63; PR, 91; RR, 19; and GCS, 10/15 and was treated in the intensive care unit.

Conclusion

Our case highlights the importance of diagnosis and on-time treatment of post-large left ventricular fibroid thrombosis complications.

Distinguishing cardiac myxomas from cardiac thrombi by a radiomics signature based on cardiovascular contrast-enhanced computed tomography images

Background

Cardiac myxomas (CMs) and thrombi are associated with high morbidity and mortality. These two conditions need totally different treatments. However, they are difficult to distinguish using naked eye. In clinical, misdiagnoses occur now and then. This study aimed to compare the characteristics of CMs and cardiac thrombi and investigate the value of a radiomics signature in distinguishing CMs from cardiac thrombi, based on cardiovascular contrast-enhanced computed tomography (CECT) images.

Methods

A total of 109 patients who had CMs (n = 59) and cardiac thrombi (n = 50) were enrolled in this retrospective study from 2009 to 2019. First, the lesion characteristics of cardiovascular CECT images were documented and compared by two radiologists. Then all patients were randomly allotted to either a primary group or a validation group according to a 7:3 ratio. Univariate analysis and the least absolute shrinkage and selection operator were used to select robust features. The best radiomics signature was constructed and validated using multivariate logistic regression. An independent clinical model was created for comparison.

Results

The best radiomics signature was developed using eight selected radiomics. The classification accuracies of the radiomics signature were 90.8% and 90.9%, and the area under the receiver operating characteristic curves were 0.969 and 0.926 in the training and testing cohorts, respectively. Cardiovascular CECT images showed that the two diseases had significant differences in location, surface, Hydrothorax, pericardial effusion and heart enlargement. The naked eye findings were used to create the clinical model. All metrics of the radiomics signature were higher than those of clinical model.

Conclusions

Compared with clinical model, the radiomics signature based on cardiovascular CECT performed better in differentiating CMs and thrombi, suggesting that it could help improving the diagnostic efficiency.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-021-01961-3.

Large left ventricular thrombus surgically resected in a patient with normal ejection: A case report

INTRODUCTION

A left ventricular thrombus is very rare in a patient with normal systolic function. We are reporting a case of left ventricular thrombus in a patient with an abnormal presentation and normal ejection fraction.

PRESENTATION OF CASE

A 57-year-old female patient presented with severe epigastric and central abdominal pain associated with nausea, vomiting, constipation, and a decrease in appetite. Post-contrast abdominal computerized tomography (CT) scan revealed multiple splenic infarcts. On echocardiographic study, a huge hyperechogenic, mobile mass was seen attached to the septo-apical wall of the left ventricle measuring 20 mm × 40 mm. Magnetic resonance imaging (MRI) also showed transmural late gadolinium enhancement in the apex which is suggestive of small myocardial infarction in the distal left anterior descending territory. Coronary angiogram showed non-occluded coronaries. The patient was treated surgically due to the urgency of the situation and the high risk of embolization.

DISCUSSION

Our patient was on both progesterone and high dose tofacitinib. It is hypothesised that patient most likely experienced asymptomatic myocardial injury with non-occluded coronaries (MINOCA) weeks prior to the presentation. Involvement of distal left anterior descending artery caused apical akinesia resulting in blood stasis. Accompanying subendocardial injury and hypercoagulable state, due to being on progesterone and tofacitinib, led to the formation of the left ventricular thrombus.

CONCLUSION

Due to the serious outcomes associated with an untreated left ventricular thrombus, it is necessary to carefully assess all patients suffering from systemic embolism with echocardiogram. Assessing the left ventricular mass with MRI was crucial to understanding the nature of the mass. Size, mobility, and protruding nature where characteristics that warranted urgent surgical intervention due to the high risk of embolization. Finally, it is important to note that tofacitinib might be a new suspect for left ventricular clots.

Massive biventricular thrombi complicating new-onset heart failure in a patient with suspected COVID-19

The World Health Organization nominated SARS-CoV-2 as the cause of the Coronavirus Disease 2019 (COVID-19) and has been granted as a pandemic. COVID-19 is an emerging threat due to the risk of microvascular, venous, and arterial thrombosis, thereby exacerbating organ injury and mortality. Although the exact mechanism of extensive thromboembolism and myocardial injury caused by SARS-CoV-2 is not illuminated, it is clear that COVID-19 related hypercoagulation increasing the fatality of the disease. Herein, we reported a patient with extensive biventricular thrombi along with the new-onset severe systolic dysfunction as an unusual catastrophic presentation of COVID-19. In our patient, there was both a right atrial "clot in transit" from his DVT as well as extensive muralized biventricular thrombus from severe global hypokinesis. We believe that the hypercoagulable state of his COVID-19 infection, along with severe systolic dysfunction, caused this unusual presentation. Although the hypercoagulable state of COVID-19 is well recognized, there have not been any reported cases of extensive de-novo intracardiac thrombus as of yet. We urge awareness of severe and potentially fatal extensive thrombosis and cardiac failure as the initial clinical presentation of possible SARS-CoV-2.

<Learning objective: Thrombotic manifestations are correlated with the high mortality rate in COVID-19; thus, strategies to prevent thrombosis have critical importance. The hypercoagulable state of COVID-19, along with cardiac injury, can lead to an extensive intracardiac thrombus and severe systolic dysfunction even in young patients who don't have previous cardiovascular comorbidities. We urge awareness of severe and potentially fatal extensive thrombosis and cardiac failure as the initial clinical presentation of COVID-19.>

Ischemic Stroke and Heart Failure: Facts and Numbers. An Update

Heart failure (HF) is a severe clinical syndrome accompanied by a number of comorbidities. Ischemic stroke occurs frequently in patients with HF as a complication of the disease. In the present review, we aimed to summarize the current state of research on the role of cardio–cerebral interactions in the prevalence, etiology, and prognosis of both diseases. The main pathophysiological mechanisms underlying the development of stroke in HF and vice versa are discussed. In addition, we reviewed the results of recent clinical trials investigating the prevalence and prevention of stroke in patients with HF.

Prevalence of intracardiac thrombi on cardiac computed tomography angiography: Outcome and impact on consequent management

Objective

Intracardiac thrombi are intermittently come across on cardiac computed tomography angiography (CCTA). This study aimed to examine the prevalence, outcome, and prognosis in patients with incidental found left-sided cardiac thrombi on CCTA.

Material and Methods

The Ethics Committee approved the present study of the Faculty of Medicine, Khon Kaen University, Khon Kaen, Thailand. A retrospective review of CCTA was performed for incidental left-sided cardiac thrombi.

Results

A total of 1080 CCTAs were enrolled with the prevalence of incidental left-sided cardiac thrombi is 4.53%. Of the 49 patients with CCTA incidental left-sided cardiac thrombi, 16 had left atrial thrombi, and 33 had left ventricular thrombi. All thrombi were undetermined before the CCTA, and their identification subsequently generated anticoagulation treatment. In 10 patients, embolic complications happened, 4 of which were fatal. Patients with incidental detected left-sided intracardiac thrombi seen by CCTA had more embolic event than patients who did not discover left-sided intracardiac thrombi by CCTA (HR = 8.07; 95% CI 1.48-44.06; p = 0.016).

Conclusions

Incidental left-sided cardiac thrombi on CCTA guided to management adjustments and seemed to present substantial mortality and morbidity in the present study. Physicians who interpret CCTA should ensure a dedicated effort not to disregard these prospective pitfalls.

Myocardial Infarction Complicated by Ischemic Stroke: Risk Factors, Prognosis, Unresolved Problems and Possible Methods of Prevention

The present work is devoted to the analysis of modern publications on various aspects of the development and course of ischemic stroke in the presence of acute myocardial infarction. A literature search was conducted on the websites of cardiological and neurological societies, as well as on the PubMed, EMBASE, eLibrary databases using the keywords: myocardial infarction, acute coronary syndrome, stroke, acute cerebrovascular accident, myocardial infarction, acute coronary syndrome, stroke. The authors of this review found that although stroke is a relatively rare complication of myocardial infarction, its prevention is an extremely significant task, since it is associated with high mortality, disability and a significant increase in the cost of treatment. So, it is extremely important to detect thrombosis of the left ventricular cavity in a timely manner, to register preexisting atrial fibrillation that occurs earlier or for the first time, followed by the appointment of anticoagulant therapy. Timely reperfusion treatment, the use of statins and modern dual antithrombotic therapy can reduce the risk of developing cerebrovascular accident in patients with myocardial infarction. It is likely that a decrease in the activity of subclinical inflammation after myocardial infarction will also reduce the risk of stroke, as was recently shown in the COLCOT study. Currently, it remains relevant to search for new knowledge about the risk factors for stroke, which complicated the course of myocardial infarction, which will allow developing more effective and personalized preventive measures in a patient with acute coronary syndrome.

Management of left ventricular thrombus: a narrative review

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.

Computational investigation of left ventricular hemodynamics following bioprosthetic aortic and mitral valve replacement

The left ventricle of the heart is a fundamental structure in the human cardiac system that pumps oxygenated blood into the systemic circulation. Several valvular conditions can cause the aortic and mitral valves associated with the left ventricle to become severely diseased and require replacement. However, the clinical outcomes of such operations, specifically the postoperative ventricular hemodynamics of replacing both valves, are not well understood. This work uses computational fluid-structure interaction (FSI) to develop an improved understanding of this effect by modeling a left ventricle with the aortic and mitral valves replaced with bioprostheses. We use a hybrid Arbitrary Lagrangian-Eulerian/immersogeometric framework to accommodate the analysis of cardiac hemodynamics and heart valve structural mechanics in a moving fluid domain. The motion of the endocardium is obtained from a cardiac biomechanics simulation and provided as an input to the proposed numerical framework. The results from the simulations in this work indicate that the replacement of the native mitral valve with a tri-radially symmetric bioprosthesis dramatically changes the ventricular hemodynamics. Most significantly, the vortical motion in the left ventricle is found to reverse direction after mitral valve replacement. This study demonstrates that the proposed computational FSI framework is capable of simulating complex multiphysics problems and can provide an in-depth understanding of the cardiac mechanics.

A case series of ventricular cystic masses

Background

Ventricular cystic masses are uncommon. Elucidating the cause is essential for early directed therapy and prevention of complications. We present two cases of ventricular cystic masses, one in each ventricle, after myocardial infarction (MI) and ventricular septal rupture (VSR), respectively.

Case summary

Patient 1 is a 58-year-old male with left brachio-facial stroke and evolved anterior MI. A left ventricular (LV) cystic thrombus was seen on transthoracic echocardiogram (TTE) and cardiac magnetic resonance (CMR) imaging. He was started on anticoagulation with reduction in thrombus size 11 days later. Patient 2 is a 67-year-old male with evolved anterior MI, severe LV systolic dysfunction, and normal right ventricular (RV) function. He was readmitted two weeks later with fever, heart failure, Streptococcus agalactiae bacteraemia, and septic pulmonary emboli. Transthoracic echocardiogram showed biventricular systolic dysfunction and a RV cystic mass associated with a partial VSR. He was treated with anticoagulation and antibiotics. Repeat TTE 5 weeks later revealed near resolution of the cystic mass and complete VSR. Cardiac magnetic resonance confirmed these findings and also showed a localized mid-septal transmural infarction at the VSR site. He underwent percutaneous coronary intervention to the left anterior descending and circumflex arteries, and percutaneous VSR closure with a muscular ventricular septal defect device later.

Discussion

Our two cases demonstrate that ventricular thrombi can present as cystic masses after MI and VSRs. Infectious, vascular, or oncogenic causes should be considered in the appropriate clinical context. Early diagnosis and treatment is essential to prevent embolic complications, and secondary infection.

Cystic left ventricular mass: the utility of transthoracic echocardiography and cardiac MRI

Accurate identification of left ventricular masses (LVM) can be challenging, and if incorrect, may have devastating consequences. While transthoracic echocardiography is often the first test to identify intracardiac masses, cardiac MRI (CMRI) allows for better anatomical definition and tissue characterisation. We present a case of a 51-year-old man who presented with 4 weeks of shortness of breath, found on echocardiogram to have severely reduced LV function and a 2.5×4.0 cm LVM with a hypolucent/cystic core. Due to the unusual appearance, CMRI was required for confirmation of an LV thrombus. This case highlights the importance of multimodality imaging in the discovery and identification of LVM.

Multiorgan thromboembolic shower and its ethical implications

A 54 year-old man was admitted after being found on the floor of his home, thought to have been there for approximately 5 days. He was diagnosed with a non-ST elevation myocardial infarction and bilateral cerebral ischaemic infarcts, as well as an acute kidney injury driven by rhabdomyolysis. The following day, bilateral lower limb ischaemia was observed. A full body CT angiogram revealed a complete thromboembolic shower with bilateral arterial occlusion in the lower limbs, bilateral pulmonary emboli, a splenic infarct and mesenteric ischaemia. An echocardiogram revealed a large thrombus in the left ventricle as the likely thromboembolic source. Bilateral lower limb amputations were recommended, commencing a complex discussion regarding the best course of management for this patient. The discussion was multifaceted, owing to the patient's lack of capacity, and input from multiple teams and the patient's relatives was required. Both ethical and clinical challenges arise from this case of a thromboembolic shower.

Patients with Left Ventricular Thrombus Despite Normal Systolic Function

The formation of a thrombus in the left ventricle (LV) in patients with normal systolic function is very rare. We report a case and identified 31 other adult patients who had an LV thrombus with normal LV systolic function. The median (IQR) age of these patients was 43 [37,59] years with a slight male predominance (59%). The vast majority of patients presented with embolic complications (28; 88%) with 3 of the other patients presenting with a febrile illness. Most of the cases occurred in the setting of an identifiable medical condition that carries an increased risk of thrombosis including inflammatory diseases, malignancies or hypereosinophilia. Treatment generally included anticoagulation with or without surgical removal or systemic thrombolysis. Recurrence of LV thrombus and/or embolic events have been reported in patients with LV thrombus and normal LV systolic function suggesting that long term anticoagulation may be needed.

Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi

Importance

Left ventricular (LV) thrombi can arise in patients with ischemic and nonischemic cardiomyopathies. Anticoagulation is thought to reduce the risk of stroke or systemic embolism (SSE), but there are no high-quality data on the effectiveness of direct oral anticoagulants (DOACs) for this indication.

Objective

To compare the outcomes associated with DOAC use and warfarin use for the treatment of LV thrombi.

Design, Setting, and Participants

A cohort study was performed at 3 tertiary care academic medical centers among 514 eligible patients with echocardiographically diagnosed LV thrombi between October 1, 2013, and March 31, 2019. Follow-up was performed through the end of the study period.

Exposures

Type and duration of anticoagulant use.

Main Outcomes and Measures

Clinically apparent SSE.

Results

A total of 514 patients (379 men; mean [SD] age, 58.4 [14.8] years) with LV thrombi were identified, including 300 who received warfarin and 185 who received a DOAC (64 patients switched treatment between these groups). The median follow-up across the patient cohort was 351 days (interquartile range, 51-866 days). On unadjusted analysis, DOAC treatment vs warfarin use (hazard ratio [HR], 2.71; 95% CI, 1.31-5.57; P = .01) and prior SSE (HR, 2.13; 95% CI, 1.22-3.72; P = .01) were associated with SSE. On multivariable analysis, anticoagulation with DOAC vs warfarin (HR, 2.64; 95% CI, 1.28-5.43; P = .01) and prior SSE (HR, 2.07; 95% CI, 1.17-3.66; P = .01) remained significantly associated with SSE.

Conclusions and Relevance

In this multicenter cohort study of anticoagulation strategies for LV thrombi, DOAC treatment was associated with a higher risk of SSE compared with warfarin use, even after adjustment for other factors. These results challenge the assumption of DOAC equivalence with warfarin for LV thrombi and highlight the need for prospective randomized clinical trials to determine the most effective treatment strategies for LV thrombi.

Predicting mortality, thrombus recurrence and persistence in patients with post-acute myocardial infarction left ventricular thrombus

Left ventricular thrombus (LVT) is a common complication of acute myocardial infarction and is associated with morbidity from embolic complications. Predicting which patients will develop death or persistent LVT despite anticoagulation may help clinicians identify high-risk patients. We developed a random forest (RF) model that predicts death or persistent LVT and evaluated its performance. This was a single-center retrospective cohort study in an academic tertiary center. We included 244 patients with LVT in our study. Patients who did not receive anticoagulation (n = 8) or had unknown (n = 31) outcomes were excluded. The primary outcome was a composite outcome of death, recurrent LVT and persistent LVT. We selected a total of 31 predictors collected at the point of LVT diagnosis based on clinical relevance. We compared conventional regularized logistic regression with the RF algorithm. There were 156 patients who had resolution of LVT and 88 patients who experienced the composite outcome. The RF model achieved better performance and had an AUROC of 0.700 (95% CI 0.553-0.863) on a validation dataset. The most important predictors for the composite outcome were receiving a revascularization procedure, lower visual ejection fraction (EF), higher creatinine, global wall motion abnormality, higher prothrombin time, higher body mass index, higher activated partial thromboplastin time, older age, lower lymphocyte count and higher neutrophil count. The RF model accurately identified patients with post-AMI LVT who developed the composite outcome. Further studies are needed to validate its use in clinical practice.

Neurologic complications of myocarditis

Myocarditis, a nonischemic acquired cardiomyopathy, is an uncommon condition with multiple presentation patterns which may be initially difficult to recognize and may simulate other conditions such as acute myocardial infarction, pericarditis, septicemia, etc. There are four distinct clinical presentation patterns that include: (1) low-grade nonspecific symptoms such as fatigue; (2) symptoms that resemble an acute myocardial infarction, especially in younger individuals; (3) a heart failure presentation which may be acute, subacute, or chronic and may be associated with cardiac conduction system defects and arrhythmias; and (4) an arrhythmia presentation that may produce sudden cardiac death, especially in young athletes with minimal or no prodromal symptoms. This chapter will provide a brief overview of various myocarditis etiologies and diagnostic modalities. The ultimate focus will be directed toward neurologic manifestations of myocarditis and its subtypes, complications of specific therapies including extracorporeal membrane oxygenation (ECMO) for refractory heart failure, and review the current literature regarding the appropriate use of therapeutic anticoagulation in myocarditis and heart failure for stroke prevention. Covid-19 infection has been discovered to cause myocarditis. The emerging science will be discussed. Nuances of brain death (BD) determination in patients receiving venoarterial ECMO for heart failure refractory to standard medical therapies will be discussed.

Antithrombotic Therapy for Patients With Left Ventricular Mural Thrombus

BACKGROUND

Contemporary data are lacking regarding the prognosis and management of left ventricular thrombus (LVT).

OBJECTIVES

The purpose of this study was to quantify the effect of anticoagulation therapy on LVT evolution using sequential imaging and to determine the impact of LVT regression on the incidence of thromboembolism, bleeding, and mortality.

METHODS

From January 2011 to January 2018, a comprehensive computerized search of LVT was conducted using 90,065 consecutive echocardiogram reports. Only patients with a confirmed LVT were included after imaging review by 2 independent experts. Major adverse cardiovascular events (MACE), which included death, stroke, myocardial infarction, or acute peripheral artery emboli, were determined as well as major bleeding events (BARC ≥3) and all-cause mortality rates.

RESULTS

There were 159 patients with a confirmed LVT. Patients were treated with vitamin K antagonists (48.4%), parenteral heparins (27.7%), and direct oral anticoagulants (22.6%). Antiplatelet therapy was used in 67.9% of the population. A reduction of the LVT area from baseline was observed in 121 patients (76.1%), and total LVT regression occurred in 99 patients (62.3%) within a median time of 103 days (interquartile range: 32 to 392 days). The independent correlates of LVT regression were a nonischemic cardiomyopathy (hazard ratio [HR]: 2.74; 95% confidence interval [CI]: 1.43 to 5.26; p = 0.002) and a smaller baseline thrombus area (HR: 0.66; 95% CI: 0.45 to 0.96; p = 0.031). The frequency of MACE was 37.1%; mortality 18.9%; stroke 13.3%; and major bleeding 13.2% during a median follow-up of 632 days (interquartile range: 187 to 1,126 days). MACE occurred in 35.4% and 40.0% of patients with total LVT regression and those with persistent LVT (p = 0.203). A reduced risk of mortality was observed among patients with total LVT regression (HR: 0.48; 95% CI: 0.23 to 0.98; p = 0.039), whereas an increased major bleeding risk was observed among patients with persistent LVT (9.1% vs. 12%; HR 0.34; 95% CI: 0.14 to 0.82; p = 0.011). A left ventricular ejection fraction ≥35% (HR: 0.46; 95% CI: 0.23 to 0.93; p = 0.029) and anticoagulation therapy >3 months (HR: 0.42; 95% CI: 0.20 to 0.88; p = 0.021) were independently associated with less MACE.

CONCLUSIONS

The presence of LVT was associated with a very high risk of MACE and mortality. Total LVT regression, obtained with different anticoagulant regimens, was associated with reduced mortality.

Left Ventricular Thrombus Therapy With Direct Oral Anticoagulants Versus Vitamin K Antagonists: A Systematic Review and Meta-Analysis

BACKGROUND

Current guidelines recommend vitamin K antagonists (VKAs) for left ventricular thrombus (LVT) resolution. Direct oral anticoagulants (DOACs) are increasingly evaluated as alternatives to the standard of care in anticoagulation.

METHODS

We performed a systematic review and meta-analysis to assess the use of DOACs vs VKAs for LVT treatment. The occurrence of LVT resolution, systemic embolism (SE) or stroke, and bleeding events were compared during follow-up using random-effects analysis.

RESULTS

The 5 included studies were all observational (a total of 828 patients). Of these, 284 patients (34%) were treated with DOACs, and 544 (66%) treated with VKAs. Thrombus resolution was similar for both methods (pooled odds ratio [OR], 0.91; 95% CI, 0.47-1.75; I ² = 63%; P = .78). The incidence of SE or stroke was also similar (pooled OR, 1.59; 95% CI, 0.85-2.97; I ² = 0%; P = .14). Clinically relevant bleeding incidence was similar for both groups (pooled OR, 0.66; 95% CI, 0.31-1.40; I ² = 0%; P = .28), although all bleeding events were less frequent in the DOAC group (pooled OR, 0.49; 95% CI, 0.26-0.90; I ² = 0%; P = .02).

CONCLUSION

Our systematic review and meta-analysis suggests DOACs were as effective as VKAs for LVT resolution, with a similar risk of systemic embolism/stroke and clinically relevant bleeding. These results, obtained from observational studies, are not definitive and hence randomized controlled trials are needed. Nevertheless, our analysis identifies key experimental features required in future studies.

Peripheral embolization following thrombolytic therapy for acute ischemic stroke—a case report

Background

Intravenous recombinant tissue plasminogen activator is the only golden approved medical therapy for acute ischemic stroke, guidelines for its injection relay on reducing or preventing associated hemorrhage as a side effect, yet hemorrhage is not the only possible complication, further embolization following injection is also a possibility; in this case report, peripheral embolization following intravenous recombinant tissue plasminogen activator with two possible explanations one related to the treatment and another related to the patient liability is represented.

Case presentation

A 78-year-old male presenting with acute onset of stroke, received intravenous recombinant tissue plasminogen activator, 16 h later he developed acute limb ischemia.

Conclusion

Peripheral embolization may happen within hours from intravenous recombinant tissue plasminogen activator administration.

Prognostic Relevance of Left Ventricular Thrombus Motility: Assessment by Pulsed Wave Tissue Doppler Imaging

Pulsed wave tissue Doppler imaging (PW-TDI) easily detects motion of cardiac structures. Hence, PW-TDI could be of value for assessing potentially cardioembolic masses. We sought to evaluate the prognostic value of left ventricular (LV) thrombus mobility assessed by PW-TDI. In 83 consecutive patients with echocardiographically detected LV thrombi, PW-TDI echocardiographic study was performed. At 1-year follow-up, the composite of major adverse cardiovascular events (MACE) defined as all-cause mortality plus hospitalizations for stroke/systemic embolism was evaluated. Seventy-two patients (77.1 ± 13.1 year/old, 32 males) were studied. All thrombi were located at the LV apex. At 1-year follow-up, 17 cardioembolic events occurred. By univariable Cox analysis, variables associated with MACE were heart rate (hazard ratio: 1.02, 95% CI: 1.00-1.05; P = .03), thrombi with mobile free edge (hazard ratio: 3.25, 95% CI: 1.25-8.44; P = .01), hypoechoic thrombi (hazard ratio: 2.86, 95% CI: 1.10-7.42; P = .03), and mass peak antegrade velocity (Va) ≥10 cm/s (hazard ratio: 8.79, 95% CI: 2.00-38.5; P = .004). By multivariable analysis, thrombi with mobile free edge (hazard ratio: 3.54, 95% CI: 1.23-10.2; P = .02), and mass peak Va ≥10 cm/s (hazard ratio: 7.97, 95% CI: 1.60-39.6; P = .01) retained statistical significance. Mass peak Va ≥10 cm/s predicted the composite end point with 94% sensitivity and 85% specificity (area under the curve = 0.86). In conclusion, PW-TDI allows objective prognostication of LV thrombi embolic risk.

Association between the E-wave propagation index and left ventricular thrombus formation after ST-elevation myocardial infarction

OBJECTIVE

To explore the association between E-wave propagation index (EPI) as a marker of apical washout and the risk of left ventricular thrombus (LVT) formation in patients with ST-elevation myocardial infarction (STEMI).

METHODS

We performed a post-hoc analysis on 364 prospectively enrolled STEMI patients from a single-center. Non-contrast transthoracic echocardiographic examinations were performed a median of 2 days (IQR:1-3 days) after PCI. The endpoint was LVT formation, identified retrospectively. Univariable and multivariable logistic regression was applied to assess the association between EPI and LVT formation. Multivariable adjustments included LVEF, LAD culprit, prior myocardial infarction, heart rate, and early myocardial relaxation velocity. Area under receiver operating characteristic curves (AUC) was used to assess the diagnostic ability.

RESULTS AND CONCLUSIONS

Among 364 patients, 31 (8.5%) developed LVT. The mean age was 62 years, 75% were men, and mean LVEF was 46%. Patients developing LVT had increased heart rate, lower LVEF, impaired GLS, and more frequently had prior myocardial infarction. Variables associated with low values of EPI included, among others, LVEF, LV aneurysm, and GLS. EPI and LVT formation were significantly associated in the univariable model (OR = 1.87 (1.53-2.28), p < 0.001), and EPI showed an AUC of 0.90. After multivariable adjustments, EPI and LVT formation remained significantly associated (OR = 1.79 (1.42-2.27), p < 0.001). Patients with an EPI < 1.0 had a 23 times higher likelihood of LVT formation (OR = 23.41 (10.06-54.49), p < 0.001). EPI and LVT formation are strongly associated in patients with STEMI, with low values of EPI indicating a markedly increased probability of LVT formation.

Unexpected death due to a biventricular thrombosis: Case report and review of literature

Cardiac thrombosis is an unusual condition characterised by the formation of a clot in the heart chambers. Biventricular thrombosis with obstruction of blood flow and fatal cardiogenic shock is anecdotal. This report describes a rare biventricular thrombosis in an elderly woman without known risk factors which was diagnosed at autopsy. A complete autopsy is essential to ascertain the cause of death, especially in complex cases with little medical history. We suggest a possible explanation for the pathophysiological mechanism.

Left ventricular apical thrombi: Silent but terrifying

We present a case with a large left ventricular (LV) thrombus that presented to the emergency department with dyspnea. Bedside transthoracic echocardiography demonstrated a huge hypermobile thrombus with a maximum of 8.6 × 2 cm in size extending to the aortic valve originating from the aneurysmatic apical wall of the LV. Treatment of the patient included complete thrombus resection with aneurysmectomy.

Infected Right Ventricle Thrombus as a Cause of Persistent Sepsis

The presentation of fevers in a patient with active intravenous (IV) drug use is often challenging, as there is a wide range of both infectious and noninfectious disorders that can cause fevers. A thorough diagnostic workup is essential in identifying the etiology of these fevers. We report a rare case of an infected right ventricular (RV) thrombus as a cause of persistent fever and sepsis in a 46-year-old patient with IV drug use. The patient continued to have persistent bacteremia inspite of appropriate IV antibiotics. Hence, the patient warranted a cardiothoracic surgical excision of the infected RV thrombus following which the patient showed remarkable improvement.

Value of the platelet-to-lymphocyte ratio in the prediction of left ventricular thrombus in anterior ST-elevation myocardial infarction with left ventricular dysfunction

Background

The predictors of left ventricular thrombus (LVT) formation are not well defined in the contemporary era, especially in those patients at high risk. We aimed to evaluate whether the platelet/lymphocyte ratio (PLR) is valuable in the determination of LVT formation in patients with anterior ST-elevation myocardial infarction (STEMI) and left ventricular (LV) dysfunction.

Methods

The LVT group (n = 46) was identified from anterior STEMI patients with LV dysfunction who were treated with primary percutaneous coronary intervention (PCI) from January 2017 to December 2019 at the China-Japan Union Hospital of Jilin University. The no-LVT group (n = 92) were also selected from the same batch of patients and were age- and sex-matched to the patients with LVT. The PLR was determined at admission and was calculated as the ratio of the platelet count to the lymphocyte count using the complete blood count. The presence of LVT was determined by echocardiography.

Results

The PLR were significantly higher in patients with LVT than in no-LVT group (p = 0.001). In a receiver operator characteristic curve (ROC) analysis, using a cut-off value of 118.07 (AUC 0.673, 95% CI: 0.574–0.771, P = 0.001), the PLR could independently predict the occurrence of LVT. Multivariate analysis showed that an increased PLR (OR = 1.011, 95% CI: 1.004–1.018, P = 0.002), the presence of a left ventricular aneurysm (OR = 46.350, 95% CI: 5.659–379.615, P < 0.001) and increased DTBT (OR = 1.005, 95% CI: 1.001–1.009, P = 0.012) were independent predictors of LVT formation.

Conclusions

In acute anterior STEMI patients with LV dysfunction, an increased PLR and DTBT and the presence of an LV aneurysm were independent predictors of LVT formation. A larger prospective study is warranted to evaluate this result.

Trial registration

This study was registered (May 4, 2019) on Chinese Clinical Trial Registry (ChiCTR-DDD-17011214).

Successful surgical transmitral removal of left ventricular thrombus after acute anterior myocardial infarction without left ventriculotomy

Left ventricular thrombus (LVT) is known as a life-threatening complication of acute myocardial infarction, in terms of sequential systemic embolization. When an LVT is found to be sufficiently large or mobile, not only anticoagulation therapy but also surgical thrombectomy should be administered immediately to prevent embolic events. Generally, since infarcted myocardium is comparatively fragile, ventriculotomy may result in anastomotic failure or further deterioration of LV function. We report herein a case of transmitral removal of LVT by which we successfully avoided ventriculotomy. A 50-year-old Japanese man was hospitalized due to ST-segment elevation myocardial infarction and emergency coronary angiography revealed total occlusion at the proximal left anterior descending artery. On hospital day 9, transthoracic echocardiography detected a massive LVT at the apex, protruding into the left ventricle. Considering the risk of embolization, urgent thrombectomy via a transmitral approach was performed. The LVT was easily removed through the mitral valve under endoscopic support, without any embolic events or postoperative complications. <Learning objective: Left ventricular thrombus following acute myocardial infarction may result in fatal embolization. Although surgical removal should be considered to prevent embolic events, some previous reports state that surgical approaches such as left ventriculotomy can lead to further cardiac dysfunction and ruptured sutures. Thus, transmitral approach may be useful for avoiding embolic events without left ventriculotomy and sequential complications.>.

A biventricular takotsubo cardiomyopathy complication: large thrombus formation to stroke in 150 min

A 67-year-old postmenopausal African American woman presented with biventricular takotsubo cardiomyopathy (TTC)-evidenced by transthoracic echocardiography (TTE) showing apical akinesis of both left and right ventricles in the absence of obstructive coronary artery disease on left heart catheterisation. On the 4th hospital day, she experienced acute left facial droop, dysarthria and dysphagia. CT of the head showed a wedge infarct of the right middle cerebral artery territory. Cardioembolism was presumed after intracranial and extracranial sources of thromboembolism were ruled out. Intravenous tissue plasminogen activator (tPA) was administered with resolution of symptoms. She was later discharged without neurological deficits. Crucially, repeat TTE after tPA infusion revealed a left ventricular mass concerning for thrombus. TTE 150 min prior to stroke onset was devoid of a mass. This case uniquely illustrates the potential for rapid thrombus formation and embolism in patients with TTC. As such, it emphasises the high index of suspicion required for management of these patients.

The use of novel oral anticoagulants compared to vitamin K antagonists (warfarin) in patients with left ventricular thrombus after acute myocardial infarction

Aim

Current guidelines recommend the use of vitamin K antagonist (VKA) for up to 3–6 months for treatment of left ventricular (LV) thrombus post-acute myocardial infarction (AMI). However, based on evidence supporting non-inferiority of novel oral anticoagulants (NOAC) compared to VKA for other indications such as deep vein thrombosis, pulmonary embolism (PE), and thromboembolic prevention in atrial fibrillation, NOACs are being increasingly used off licence for the treatment of LV thrombus post-AMI. In this study, we investigated the safety and effect of NOACs compared to VKA on LV thrombus resolution in patients presenting with AMI.

Methods and results

This was an observational study of 2328 consecutive patients undergoing coronary angiography ± percutaneous coronary intervention (PCI) for AMI between May 2015 and December 2018, at a UK cardiac centre. Patients’ details were collected from the hospital electronic database. The primary endpoint was rate of LV thrombus resolution with bleeding rates a secondary outcome. Left ventricular thrombus was diagnosed in 101 (4.3%) patients. Sixty patients (59.4%) were started on VKA and 41 patients (40.6%) on NOAC therapy (rivaroxaban: 58.5%, apixaban: 36.5%, and edoxaban: 5.0%). Both groups were well matched in terms of baseline characteristics including age, previous cardiac history (previous myocardial infarction, PCI, coronary artery bypass grafting), and cardiovascular risk factors (hypertension, diabetes, hypercholesterolaemia). Over the follow-up period (median 2.2 years), overall rates of LV thrombus resolution were 86.1%. There was greater and earlier LV thrombus resolution in the NOAC group compared to patients treated with warfarin (82% vs. 64.4%, P = 0.0018, at 1 year), which persisted after adjusting for baseline variables (odds ratio 1.8, 95% confidence interval 1.2–2.9). Major bleeding events during the follow-up period were lower in the NOAC group, compared with VKA group (0% vs. 6.7%, P = 0.030) with no difference in rates of systemic thromboembolism (5% vs. 2.4%, P = 0.388).

Conclusion

These data suggest improved thrombus resolution in post-acute coronary syndrome (ACS) LV thrombosis in patients treated with NOACs compared to VKAs. This improvement in thrombus resolution was accompanied with a better safety profile for NOAC patients vs. VKA-treated patients. Thus, provides data to support a randomized trial to answer this question.

A case of nonvalvular endocarditis with biventricular apical infected thrombi

We report what appears to be the first case of biopsy-proven nonvalvular endocarditis with biventricular apical infected thrombi. A 47-year-old man presented with hypoxic respiratory failure from a multilobar pneumonia due to methicillin-resistant Staphylococcus aureus (MRSA). Transthoracic echocardiography and cardiac magnetic resonance imaging revealed biventricular apical masses suggestive of nonvalvular endocarditis with infected thrombi. Given concern for ongoing septic embolization to the lungs and brain despite appropriate antimicrobial therapy, the masses were surgically resected. Culture and histopathology confirmed MRSA-positive infected thrombi. In this case report, we highlight the differential diagnosis of apical masses and the role of multimodality imaging.

Left ventricle unloading strategies in ECMO: A single-center experience

INTRODUCTION

Extracorporeal membrane oxygenation (ECMO) is a life-saving technology capable of restoring perfusion but is not without significant complications that limit its realizable therapeutic benefit. ECMO-induced hemodynamics increase cardiac afterload risking left ventricular distention and impaired cardiac recovery. To mitigate potentially harmful effects, multiple strategies to unload the left ventricle (LV) are used in clinical practice but data supporting the optimal approach is presently lacking.

MATERIALS & METHODS

We reviewed outcomes of our ECMO population from September 2015 through January 2019 to determine if our LV unloading strategies were associated with patient outcomes. We compared reactive (Group 1, n = 30) versus immediate (Group 2, n = 33) LV unloading and then compared patients unloaded with an Impella CP (n = 19) versus an intra-aortic balloon pump (IABP, n = 16), analyzing survival and ECMO-related complications.

RESULTS

Survival was similar between Groups 1 and 2 (33 vs 42%, P = .426) with Group 2 experiencing more clinically-significant hemorrhage (40 vs. 67%, P = .034). Survival and ECMO-related complications were similar between patients unloaded with an Impella versus an IABP. However, the Impella group exhibited a higher rate of survival (37%) than predicted by their median SAVE score (18%).

DISCUSSION

Based on this analysis, reactive unloading appears to be a viable strategy while venting with the Impella CP provides better than anticipated survival. Our findings correlate with recent large cohort studies and motivate further work to design clinical guidelines and future trial design.

The neutrophil-lymphocyte ratio and platelet-lymphocyte ratio predict left ventricular thrombus resolution in acute myocardial infarction without percutaneous coronary intervention

BACKGROUND

Left ventricular thrombosis (LVT) is a potentially devastating complication in post-acute myocardial infarction (AMI) patients. Previous studies have demonstrated that inflammation may contribute to thrombus formation, but its role on thrombus resolution is uncertain. The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are easily accessible haematological markers of inflammation.

OBJECTIVES

We aimed to identify differences between post-AMI LVT patients with and without LVT resolution, and to evaluate the utility of NLR and PLR in predicting LVT resolution.

METHODS

We included 289 consecutive post-AMI patients with LVT. Acute LVT was diagnosed based on echocardiogram. Patients were stratified based on LVT resolution. Logistic regression was performed to evaluate for independent predictors of thrombus resolution.

RESULTS

Compared to post-AMI patients with eventual LVT resolution, those with unresolved LVT had more co-morbidities such as hypertension (p = 0.003) and ischaemic heart disease (p < 0.001), fewer underwent percutaneous coronary intervention (PCI) (p < 0.001) or were treated with triple therapy (p < 0.001). NLR (p = 0.064) and PLR (p = 0.028) were higher in unresolved LVT patients. In non-PCI patients, NLR (OR 0.818, 95% CI 0.674-0.994, p = 0.043) and PLR (OR 0.989, 95% CI 0.979-0.999, p = 0.026) were independent predictors of thrombus resolution after adjustment for age and anticoagulation use.

CONCLUSIONS

Post-AMI patients not receiving PCI may have a greater inflammatory response and a higher NLR and PLR, which is associated with less LVT resolution despite anticoagulation. Further studies are required to study this association.

Direct Oral Anticoagulants for the Treatment of Left Ventricular Thrombus-A New Indication? A Meta-summary of Case Reports

Left ventricular thrombus (LVT) can be a consequence of cardiac diseases such as heart failure with reduced ejection fraction and acute myocardial infarction. Currently, the guidelines recommend the use of warfarin for the treatment of this condition. However, there are increasing reports of patients with LVTs being treated with direct oral anticoagulants (DOACs), for several reasons. We set out to review the available literature to assess the safety and the efficacy of this approach. We analyzed 52 cases, extrapolated by 34 papers contained in literature, focusing on the characteristics of patients, treatment, outcome, and follow-up. Rivaroxaban was the most commonly used DOAC, followed by apixaban. The diagnosis of LVT and the follow-up were mainly performed by transthoracic echocardiography. The thrombus resolved in 45 patients (92%) of 49 (there are no data available regarding the outcome of 3 patients) and failed to resolve in 4 patients treated with DOACs. The resolution occurred in a median of 32 days. DOACs are shown to be a reasonable and valid option for the treatment of LVT. Our study provides a rationale for a prospective randomized controlled trial.

Peripheral Embolization of Left Ventricular Thrombus Leading to Acute Bilateral Critical Limb Ischemia: A Rare Phenomenon

Left ventricular thrombus (LVT) is a well-known complication of myocardial infarction (MI) leading to significant morbidity and mortality. LVT can also lead to systemic thromboembolic events causing threatening limb ischemia. We report a rare case of critical bilateral limb ischemia that resulted from peripheral embolization of LVT post MI, which was managed successfully by emergent surgical intervention and anticoagulation. A 74-year-old male with a medical history of hypertension, diabetes, hyperlipidemia and coronary artery disease status post stenting of the left anterior descending and left circumflex arteries presented to the emergency department with typical chest pain and progressive shortness of breath. Cardiac troponin levels on admission were 35 ng/mL of blood. The patient subsequently underwent emergent cardiac catheterization which revealed significant triple vessel disease, and was referred for coronary artery bypass grafting (CABG) surgery. Transthoracic and transesophageal echocardiograms revealed the presence of an apical aneurysm with chronic organized mobile thrombus at the apex. Post CABG, the patient complained of excruciating right leg pain. Computed tomography (CT) angiogram of the abdominal aorta and lower extremities revealed a large embolus at the aortic bifurcation occluding the right and nearly occluding the left common iliac arteries and thrombus in the right popliteal artery. He underwent emergent vascular surgery with resolution of his symptoms and remained without further complications. The incidence of LVT remains high in post-MI patients, and complications of LVT are known to include thromboembolic events. Peripheral embolization of acute or chronic LVT leading to bilateral distal embolization and critical limb ischemia remains a rare occurrence. This case report aims to aid clinicians to recognize and promptly manage LVT and related arterial thromboembolic events with anticoagulation and emergent surgical intervention if limb ischemia develops.

The prognostic effect of left ventricular thrombus formation after acute myocardial infarction in the contemporary era of primary percutaneous coronary intervention: A meta-analysis

BACKGROUNDS

The prognosis and management of left ventricular thrombus (LVT) following acute myocardial infarction (AMI) have not been well evaluated since the advent of primary percutaneous coronary intervention (PCI). We therefore conducted a meta-analysis to assess the prognostic effect of LVT after AMI in primary PCI era and investigate the impact of triple therapy on outcomes.

METHODS

We searched MEDLINE, EMBASE and the Cochrane Library for studies conducted in primary PCI era up to 29 March 2019, compering the incidence of embolic events and mortality after AMI between LVT patients and Non-LVT patients. Random-effect models were used. Subgroup analysis was done by comparing triple therapy treated LVT group with Non-LVT group.

RESULT

A total of 12 studies were included. LVT was associated with increased risk of embolic events and long-term mortality (RR 3.97, 95%CI 2.68-5.89, P < 0.0001; RR 2.34, 95%CI 1.38-3.96, P = 0.002). Subgroup analysis was also done by comparing triple therapy treated LVT group with Non-LVT group. Despite a downward tendency was observed, the embolic risk of triple therapy subgroup was higher than non-LVT group (RR 2.79, 95%CI 1.32-5.91, P = 0.007). Triple therapy subgroup had a similar mortality rate compared with non-LVT group (RR 0.93, 95%CI 0.34-2.52, P = 0.88).

CONCLUSION

In primary PCI era, LVT formation after AMI indicated a fourfold increased embolic risk and twofold long-term mortality rate. Triple therapy may be a safe way to improve the outcomes, but still need to be confirmed by future trials.

Sudden death due to left ventricular thrombosis: A report of two autopsy cases

PURPOSE

In this paper, we report two rare cases of sudden death due to giant left ventricular thrombus revealed at autopsy and we discuss the manner and the cause of death.

RESULTS

Cases presentation: The two cases reported are about two men aged 55 and 53 years respectively. In the two cases, no past cardiac history was found. Prior to the onset of complications and subsequent death, both patients presented to the emergency department with progressing asthenia, faintness and shortness of breath, were treated symptomatically. At autopsy, atherosclerosis of coronary arteries was found. In the first case, death was attributed to thrombosis of the pseudoaneurysm. In the second case, it was due to thrombosis complicating a myocardial infarction. The mechanism of death in the first case was explained by the hemodynamic shock caused by a total left ventricular pseudoaneurysm thrombosis secondary to old myocardial infraction. In the second case, death was the consequence of a cardiogenic shock secondary to thrombosis of the cardiac pseudoaneurysm complicating a myocardial infraction.

CONCLUSION

Complications of myocardial infarction represent frequent causes of adult sudden death. Left ventricular thrombosis is a complication that is often fatal and its discovery during an autopsy remains rare. The first-line doctor must take these types of complications into consideration in order to detect them and thus ensure timely management.