A 43-year-old woman presented with dyspnea, shock and abdominal pain. Hemorrhagic bulbitis had been diagnosed one week earlier in another hospital, for which proton pump inhibitors were prescribed. She had no other medical history. Urgent transesophageal echocardiography revealed a dilated cardiomyopathy with poor biventricular function, pulmonary hypertension and multiple, large apical thrombi (Figure 1 and video). The patient went into cardiac arrest and died despite extensive resuscitation efforts. At autopsy, infarction of the lower lobe of the right lung (Figure 2) as well as multiple bilateral segmental pulmonary emboli were identified. Duodenal infarction and multiple smaller jejunal infarctions were also seen (not shown). The left ventricular apex was filled with several large and small thrombi (Figure 3), whereas the right ventricular apex contained only a small thrombus. The origin of the cardiomyopathy could not be established.
Figure 1).
Transesophageal echocardiography revealing a dilated cardiomyopathy with poor biventricular function and multiple large apical thrombi (arrows)
Figure 2).
Infarction of the lower lobe of the right lung (arrow)
Figure 3).
Longitudinal section of the left ventricle revealing several large and small thrombi (arrows)
Left ventricular apical thrombi are not uncommon (1,2).Biventricular thrombus formation with both pulmonary and systemic embolization is exceptional. To the best of our knowledge, only two cases of documented embolization into the pulmonary and systemic circulation have been reported in patients with dilated cardiomyopathy (3,4).
Supplementary Material
REFERENCES:
- 1.Waller BF, Grider L, Rohr TM, McLaughlin T, Taliercio CP, Fetters J. Intracardiac thrombi: Frequency, location, etiology and complications: A morphological review – Part I. Clin Cardiol. 1995;18:477–9. doi: 10.1002/clc.4960180811. [DOI] [PubMed] [Google Scholar]
- 2.Wilensky RL, Jung SC. Thromboembolism in patients with decreased left ventricular function: Incidence, risk, and treatment. J Cardiovasc Risk. 1995;2:91–6. [PubMed] [Google Scholar]
- 3.Minor RL, Oren RM, Stanford W, Ferguson DW. Biventricular thrombi and pulmonary emboli complicating idiopathic dilated cardiomyopathy: Diagnosis with cardiac ultrafast CT. Am Heart J. 1991;122:1477–81. doi: 10.1016/0002-8703(91)90598-c. [DOI] [PubMed] [Google Scholar]
- 4.Missault L, Koch A, Colardyn F, Clement D. Biventricular thrombi in dilated cardiomyopathy: Massive simultaneous pulmonary and systemic embolisation. Eur Heart J. 1994;15:713–4. doi: 10.1093/oxfordjournals.eurheartj.a060574. [DOI] [PubMed] [Google Scholar]
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