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Internal Medicine
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Case Report
Abstract
Background: Intracavitary thrombi are a known complication of ischemic cardiomyopathy, often arising in the setting of severely reduced left ventricular ejection fraction. These thrombi can predispose patients to thromboembolic events and exacerbate cardiovascular compromise. Diagnostic challenges arise when intracavitary masses are identified in conjunction with other critical pathologies, such as acute coronary syndromes or peripheral artery disease. This report highlights the case of a 74-year-old male with multiple cardiovascular comorbidities who presented with near syncope, non-ST elevation myocardial infarction, and an incidental finding of an intracavitary left ventricular thrombus.
Case Presentation: A 74-year-old male with a history of coronary artery disease, peripheral artery disease, hypertension, and heavy tobacco use presented to the emergency department with recurrent dizziness, near-syncope, and occasional episodes of chest pain. He denied exertional or positional triggers and had no shortness of breath or loss of consciousness. On initial examination, the patient was hypotensive and reported intermittent left leg numbness without associated pain. Physical examination revealed a cold left lower extremity with intact distal movement.
Laboratory results showed elevated troponin levels in the 2500s. Coronary angiography confirmed 100% occlusion of the left anterior descending artery, leading to the diagnosis of NSTEMI. Medical management was initiated, including dual antiplatelet therapy (aspirin and clopidogrel), high-intensity statin therapy, and therapeutic anticoagulation with low-molecular-weight heparin.
Transthoracic echocardiography revealed a severely reduced left ventricular ejection fraction of 20-25%, with global hypokinesis. A mobile intracavitary mass in the left ventricular septum raised concerns for a left ventricular thrombus. Additionally, a CTA Chest revealed a 5 x 5.3 x 6.1 cm soft tissue non-enhancing masslike lesion involving the apex of the left ventricle, which was highly suspicious for a large left ventricular thrombus.
Due to the suspected left ventricular thrombus, the patient was transitioned to Eliquis 5 mg PO BID for anticoagulation. This decision was made as part of his medical management for the intracavitary thrombus.
The patient also experienced bradycardia prompting a consult with electrophysiology. EP studies revealed severe sinus node dysfunction and inducible ventricular tachycardia that deteriorated into ventricular fibrillation, requiring cardioversion. As a result, an automatic cardiac implantable device (ACID) was placed for further arrhythmia management and to reduce the risk of sudden cardiac death.
The patient was discharged with anticoagulation therapy (apixaban and clopidogrel) for the management of the intracavitary thrombus and was instructed to follow up with cardiology for further management of his arrhythmias and heart failure.
Discussion and Conclusion: This case highlights the critical importance of evaluating intracavitary thrombi in patients with severe ischemic cardiomyopathy. Therapeutic anticoagulation is the mainstay of management to reduce the risk of embolization, as surgical thrombectomy or revascularization may not be feasible in patients with significant comorbidities and medical fragility1.
The patients severely reduced left ventricular ejection fraction of 20-25% is an established risk factor for the development of intracavitary thrombus2,3. Low EF leads to impaired ventricular function, stasis, and increased thrombus formation, making anticoagulation therapy even more crucial in preventing thromboembolic complications2.
The presence of coexisting peripheral artery disease and chronic left anterior descending artery occlusion further complicates management, necessitating a multidisciplinary approach to prioritize interventions3. This case underscores the importance of early identification and the implementation of tailored treatment strategies for intracavitary thrombi in patients with severe cardiovascular disease, including appropriate anticoagulation and close monitoring for potential embolic events.
Recommended Citation
Mogollon, Ivan; Salcedo, Luis; Arias, Francisco; Calderon, Aura; Matos, Catherine; and Cantu, Ismael, "Intracavitary Left Ventricular Thrombus in a Patient with Severe Ischemic Cardiomyopathy and NSTEMI: A Case Report and Management Approach" (2025). Research Symposium. 70.
https://scholarworks.utrgv.edu/somrs/2025/posters/70
Included in
Intracavitary Left Ventricular Thrombus in a Patient with Severe Ischemic Cardiomyopathy and NSTEMI: A Case Report and Management Approach
Background: Intracavitary thrombi are a known complication of ischemic cardiomyopathy, often arising in the setting of severely reduced left ventricular ejection fraction. These thrombi can predispose patients to thromboembolic events and exacerbate cardiovascular compromise. Diagnostic challenges arise when intracavitary masses are identified in conjunction with other critical pathologies, such as acute coronary syndromes or peripheral artery disease. This report highlights the case of a 74-year-old male with multiple cardiovascular comorbidities who presented with near syncope, non-ST elevation myocardial infarction, and an incidental finding of an intracavitary left ventricular thrombus.
Case Presentation: A 74-year-old male with a history of coronary artery disease, peripheral artery disease, hypertension, and heavy tobacco use presented to the emergency department with recurrent dizziness, near-syncope, and occasional episodes of chest pain. He denied exertional or positional triggers and had no shortness of breath or loss of consciousness. On initial examination, the patient was hypotensive and reported intermittent left leg numbness without associated pain. Physical examination revealed a cold left lower extremity with intact distal movement.
Laboratory results showed elevated troponin levels in the 2500s. Coronary angiography confirmed 100% occlusion of the left anterior descending artery, leading to the diagnosis of NSTEMI. Medical management was initiated, including dual antiplatelet therapy (aspirin and clopidogrel), high-intensity statin therapy, and therapeutic anticoagulation with low-molecular-weight heparin.
Transthoracic echocardiography revealed a severely reduced left ventricular ejection fraction of 20-25%, with global hypokinesis. A mobile intracavitary mass in the left ventricular septum raised concerns for a left ventricular thrombus. Additionally, a CTA Chest revealed a 5 x 5.3 x 6.1 cm soft tissue non-enhancing masslike lesion involving the apex of the left ventricle, which was highly suspicious for a large left ventricular thrombus.
Due to the suspected left ventricular thrombus, the patient was transitioned to Eliquis 5 mg PO BID for anticoagulation. This decision was made as part of his medical management for the intracavitary thrombus.
The patient also experienced bradycardia prompting a consult with electrophysiology. EP studies revealed severe sinus node dysfunction and inducible ventricular tachycardia that deteriorated into ventricular fibrillation, requiring cardioversion. As a result, an automatic cardiac implantable device (ACID) was placed for further arrhythmia management and to reduce the risk of sudden cardiac death.
The patient was discharged with anticoagulation therapy (apixaban and clopidogrel) for the management of the intracavitary thrombus and was instructed to follow up with cardiology for further management of his arrhythmias and heart failure.
Discussion and Conclusion: This case highlights the critical importance of evaluating intracavitary thrombi in patients with severe ischemic cardiomyopathy. Therapeutic anticoagulation is the mainstay of management to reduce the risk of embolization, as surgical thrombectomy or revascularization may not be feasible in patients with significant comorbidities and medical fragility1.
The patients severely reduced left ventricular ejection fraction of 20-25% is an established risk factor for the development of intracavitary thrombus2,3. Low EF leads to impaired ventricular function, stasis, and increased thrombus formation, making anticoagulation therapy even more crucial in preventing thromboembolic complications2.
The presence of coexisting peripheral artery disease and chronic left anterior descending artery occlusion further complicates management, necessitating a multidisciplinary approach to prioritize interventions3. This case underscores the importance of early identification and the implementation of tailored treatment strategies for intracavitary thrombi in patients with severe cardiovascular disease, including appropriate anticoagulation and close monitoring for potential embolic events.
