Live Echocardiographic Visualization of the Migration of a Voluminous Left Ventricular Thrombus Complicating an Acute Myocarditis
A 52-year-old man was referred to our intensive care unit by the emergency department for chest pain and severe recent-onset dyspnea. The patient had no particular medical history and no cardiovascular risk factors. His complaints started 3 weeks previously after what he described as a severe flu with cough and fever.
At clinical examination, the patient was breathless with a respiratory rate of 28 cycles per minute and a fever of 38.3°C. His heart rate was 88 bpm and blood pressure was 112/68 mm Hg. Pulmonary auscultation revealed bilateral wet rales in the lower lung fields. An ECG showed no particularities. Biology found a frank inflammatory syndrome with an erythrocyte sedimentation rate of 90, a C-reactive protein of 180 mg/L, and a white blood cell count of 14 500. His troponin I level was 6.4 mg/L and BNP level was 6788 pg/mL.
Transthoracic echocardiography performed at admission (Figure 1 and Movie I of the online-only Data Supplement) showed a severely depressed left ventricular function with an ejection fraction of ≈30%, along with a massive apical adherent thrombus. Another spherical, highly mobile, pedunculated thrombus was observed, as well as a circumferential pericardial effusion and an important pleural effusion.
Given the potentially high risk of distal embolization, an urgent surgery was discussed; meanwhile, the patient was treated with unfractionated heparin. A second echocardiographic control was performed just 1 hour later, which showed an impressive live preprocedural migration of the mobile thrombus from the left ventricular apex toward the outlet chamber and through the aortic orifice to the systemic circulation (Figure 2 and Movie II of the online-only Data Supplement). Extraordinarily and fortunately, no symptomatic embolic event was noted. A whole-body computed tomography scan showed no signs of infarction or embolization; Doppler echocardiography of the lower limbs and renal arteries also proved normal, as did the coronary angiogram. The final presumptive diagnosis of acute myocarditis complicated by an asymptomatic embolization was made. Anticoagulation with unfractionated heparin was continued, but surgery was canceled. The evolution was favorable, with rapid clinical improvement and partial recovery of ventricular function with a notable reduction in thrombus size. U.S. was discharged home on day 10 with angiotensin-converting enzyme inhibitors, β-blockers, diuretics, and Coumadin. On the control performed 1 month later, he was completely symptom free, and echocardiography revealed no abnormalities (Figure 3 and Movie III of the online-only Data Supplement).
The online-only Data Supplement is available at http://circ.ahajournals.org/cgi/content/full/120/2/e8/DC1.