Not So Mural Thrombus
A 64-year-old man with type 2 diabetes mellitus was admitted to our emergency department for a 12-hour history of waxing and waning chest pain. During the first hour of observation, he complained about a new episode of chest pain accompanied by ST elevation in leads V2 and V3. The patient underwent emergency coronary angiography that showed 80% stenosis of the proximal left anterior descending artery with subocclusive thrombotic lesion of its middle segment and TIMI-1 distal flow. Contrast ventriculography revealed left ventricular apical hypokinesia; primary angioplasty and stent implantation on the left anterior descending artery were performed. The patient was admitted to the coronary care unit and treated with β-blockers, captopril, unfractionated heparin, tirofiban, aspirin, and clopidogrel. Clinical, ECG, and biochemical signs of reperfusion were observed. Peak creatine phosphokinase was 696 U/L, with 35 μg/L of the MB isoform. At the sixth day after admission, before the planned discharge, a standard second harmonic echocardiographic study (Sonos 5500 with S3 probe) revealed a hypokinetic apex with preserved wall thickness and a large mural thrombus (Movie I). Contrast echocardiography, performed to improve the definition of thrombus morphology (Figure 1 and Movie II), showed that the left ventricular thrombus was mobile and largely detached. This finding significantly increased the risk of embolism; therefore, the patient was not discharged, and full anticoagulation therapy with unfractionated heparin was started.
The elevated potential embolic risk was confirmed after 5 days of therapy by a new contrast echocardiography study (Figure 2 and Movie III), which showed increased thrombus mobility. Two weeks after admission, echocardiography showed complete thrombus resolution. The patient was discharged on oral anticoagulants.
The online-only Data Supplement, which contains Movie I through Movie III, can be found at http://circ.ahajournals.org/cgi/content/full/113/3/e38/DC1.