When a Thrombus Is Life-Saving
2015; Lippincott Williams & Wilkins; Volume: 132; Issue: 16 Linguagem: Inglês
10.1161/circulationaha.115.017317
ISSN1524-4539
Autores Tópico(s)Atrial Fibrillation Management and Outcomes
ResumoHomeCirculationVol. 132, No. 16When a Thrombus Is Life-Saving Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissionsDownload Articles + Supplements ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toSupplemental MaterialFree AccessResearch ArticlePDF/EPUBWhen a Thrombus Is Life-Saving Abdalla Elagha, MD, PhD and Azza Farrag, MD, PhD Abdalla ElaghaAbdalla Elagha From Department of Cardiology, Cairo University Hospitals, Cairo, Egypt (A.E., A.F.); and Translational Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (A.E.). and Azza FarragAzza Farrag From Department of Cardiology, Cairo University Hospitals, Cairo, Egypt (A.E., A.F.); and Translational Medicine Branch, National Heart, Lung, and Blood Institute, Bethesda, MD (A.E.). Originally published20 Oct 2015https://doi.org/10.1161/CIRCULATIONAHA.115.017317Circulation. 2015;132:e199–e201A 37-year-old previously healthy man, a manual sugarcane juicer who lives in a rural area, presented with a 1-month history of atypical chest pain in his left shoulder area and a 2-week history of breathlessness on moderate exertion. On admission, the patient was tachycardic and tachypneic and had a blood pressure of 90/60 mm Hg with pulsus paradoxus. Physical examination showed elevated jugular venous pressure and distant heart sounds. ECG revealed ST-segment elevation in the anterior precordial leads (Figure 1A), but his troponin level was normal. Chest x-ray demonstrated an increased cardiothoracic ratio with a flask-shape appearance (Figure 1B). Echocardiography demonstrated massive pericardial effusion with signs of tamponade, left ventricular mass, and dyskinetic apex (Figure 1C and Movie I in the online-only Data Supplement). On the basis of previous investigations, urgent pericardiocentesis was performed; 2000 cm3 of hemorrhagic fluid was aspirated and sent for laboratory investigations. One day later, reaccumulation of pericardial fluid occurred. Cardiac magnetic resonance imaging was requested for further investigations. Surprisingly, a small area of perforation in the dyskinetic apex was demonstrated (Figure 2A). Uncommonly, this perforation was sealed from the inside rather than outside by a left ventricular thrombus, slowing the amount of blood escaping the left ventricular cavity and improving the prognosis (Figure 2B and Movie II in the online-only Data Supplement). Moreover, delayed-hyperenhancement images clearly showed the scar in the left ventricular apex and adjacent segments, with the nonenhanced thrombus overlying it (Figure 2C).Download figureDownload PowerPointFigure 1. A, Twelve-lead ECG showed ST-segment elevation in the anterior precordial leads. B, Chest x-ray, posteroanterior view, demonstrated increased cardiothoracic ratio with a flask-shape appearance. C, Echocardiography demonstrated massive pericardial effusion, left ventricular mass, and dyskinetic apex.Download figureDownload PowerPointFigure 2. A, A small area of perforation in the dyskinetic apex was depicted with T1-weighted axial magnetic resonance imaging (MRI; white arrow). B, Steady-state free-precession MRI in the 4-chamber view revealed a large left ventricular (LV) thrombus (arrowhead), sealing the perforation from the inside rather than the outside and slowing the amount of blood escaping the LV cavity. C, Delayed-hyperenhancement MRI, 4-chamber view, showed a scar in the LV apex and adjacent segments denoting the left anterior descending artery territory (small white arrowheads). Note that the LV thrombus is located at the LV apex with no gadolinium uptake (white arrow). Pericardial effusion is noted (asterisk).Urgent coronary angiography showed total proximal left anterior descending artery occlusion (Figure 3), after which urgent surgical intervention was performed. In the operating room, magnetic resonance imaging findings were confirmed, and a left ventricular aneurysmectomy (Figure 4A), evacuation of a huge mural thrombus (Figure 4B), ventricular reconstruction (Figure 4C), and a left internal mammary artery graft to the left anterior descending artery were performed.Download figureDownload PowerPointFigure 3. Coronary angiography (in the right anterior oblique view) showed total proximal left anterior descending artery occlusion (white arrow).Download figureDownload PowerPointFigure 4. A, Surgical view of the left ventricular aneurysmectomy. B, Evacuation of mural thrombus (pieced). C, Surgical view after the ventricular reconstruction.When myocardial infarction is complicated by myocardial rupture, usually it occurs within 2 weeks of onset.1 If not diagnosed early and treated promptly, it is fatal.2 However, in this educational case, the formation of a large apical thrombus in the left ventricle overlying the site of myocardial rupture offered a sealing mechanism that decreased the rate of bleeding into the pericardium and temporarily saved the patient from sudden collapse and death.AcknowledgmentWe would like to thank Dr Waleed Ammar, Dr Alaa Farouk, and Dr Amr Youssef for their kind help in management of this patient.DisclosuresNone.FootnotesThe online-only Data Supplement is available with this article at http://circ.ahajournals.org/lookup/suppl/doi:10.1161/CIRCULATIONAHA.115.017317/-/DC1.Correspondence to Abdalla Elagha, MD, PhD, Cardiovascular Department, Kasr-Alaini Hospital, 1 Saraya St, Third Floor, Manial, Cairo, Egypt 11211. 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October 20, 2015Vol 132, Issue 16 Advertisement Article InformationMetrics © 2015 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.115.017317PMID: 26481567 Originally publishedOctober 20, 2015 PDF download Advertisement SubjectsComputerized Tomography (CT)ImagingMagnetic Resonance Imaging (MRI)
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