A 69-year-old man was admitted to the emergency department with dyspnea. His medical history was remarkable for smoking (75 pack-years), chronic obstructive pulmonary disease and ischemic cardiomyopathy. On physical examination, his blood pressure was 100/80 mmHg, his pulse rate was 104 beats/min and he had bilateral moderate pretibial edema. Cardiac auscultation revealed a 2/6 systolic murmur at the apex with distant heart sounds. Auscultation of the lungs revealed bilateral rales with diffuse rhonchi in the lower lobes. On a 12-lead electrocardiogram, poor progression of the pre-cordial R wave and P mitrale were noticed. Two-dimensional echocardiography displayed diffuse left ventricular hypokinesia with an estimated ejection fraction of 15%. A cystic thrombus that did not have a germinative membrane was found at the apex of the left ventricle (Figure 1). Pulmonary computed tomography angiography showed a filling defect in the left ventricle. Tests for Echinococcus granulosus were negative. Heparin, warfarin and heart failure treatment were started. One week later, echocardiography showed that the size of the thrombus had decreased by 25%. The patient did not have any complication related to the thrombus.
Figure 1).
Left ventricular apical cystic thrombus
Left ventricular thrombus is a common complication of severe heart failure. Therapeutic options for such thrombi include anti-thrombotics, anticoagulant therapy, thrombolysis or surgical removal of the thrombus. Clinicians should also consider hydatid cysts in the differential diagnosis, when history and laboratory tests could be used to confirm the diagnosis. But overall, until the diagnosis is established, treatment should also be initiated for a probable diagnosis of thrombus (1,2).
REFERENCES
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