Unusual appearance of a left ventricular mural thrombus
by Dwarakraj Soundarraj, MD • Thomas Schultz, DO • Leslie A. Brookfield, MD
From Advocate Lutheran General Hospital, Park Ridge, Illinois.
INTRODUCTION
Postpartum cardiomyopathy is a serious disorder that can present from the third trimester to up to 5 months after pregnancy. Although spontaneous resolution of cardiac function occurs in more than half of patients (over a period of 6-12 months), the balance is left with persistent cardiac dysfunction. Cardiac dysfunction results in signs and symptoms of left heart failure, formation of apical or left ventricular thrombi, and arrhythmias and requires management similar to that in patients with nonischemic dilated cardiomyopathy. The disease is associated with 15% to 20% mortality. Soundarraj and colleagues present a patient with peripartum cardiomyopathy who had an unusual cystic-appearing thrombus in the left ventricle that resolved with anticoagulant treatment and with improvement of left ventricular function. Such appearance of thrombus is unusual and may result—as the authors point out—from unbalanced lytic and thrombotic factors. Embolization of highly mobile masses is a concern, especially with rapid improvement in left ventricular function as in this case, but apparently this patient's thrombus resolved without complications. This author has seen cystic appearance of vegetations occasionally. Differential diagnosis of choriocarcinoma in the clinical setting is appropriate. Other diagnoses to consider when there is an echocardiographic detection of a cystic mass include cavernous hemangioma,1 papillary fibroelastoma,2 echinoccus cyst in the heart,3 cardiac lymphangiomas,4 and myxomas.5,6
—Tasneem Z. Naqvi, MD, MRCP
Cedars Sinai Maedical Center
Los Angeles, California
References
- Perez-Sanz TM, Fulquet E, Neilan TG, et al. A case report of a round cystic tumor in the left ventricular outflow tract. J Am Soc
Echocardiogr. 2006;19(11):1402.e9-1402.e11.
- Kim HK, Kim YJ, Chang SA, et al. Cardiac papillary fibroelastoma manifested as a left ventricular cystic mass. Int J Cardiol. 2005;101(3):507-508.
- Ben-Hamda K, Maatouk F, Ben-Farhat M, et al. Eighteen-year experience with echinococcosus of the heart: clinical and echocardiographic features in 14 patients. Int Cardiol. 2003; 91(2-3):145-151.
- Araoz PA, Mulvagh SL, Tazelaar HD, et al. CT and MR imaging of benign primary cardiac neoplasms with echocardiographic correlation. Radiographics. 2000;20(5):1303-1319.
- Ibanez B, Marcos-Alberca P, Rey M, et al. Multicavitated left atrial myxoma mimicking a hydatid cyst. Eur J Echocardiogr. 2005;6(3):231-233.
- Izgi A, Kirma C, Mansuroglu D, et al. Giant cystic left atrial myxoma as a cause of secondary pulmonary hypertension. Echocardiography. 2005;22(1):49-50.
Presentation and evaluation
A 36-year-old female presented 3 weeks after cesarean section with fatigue, loss of appetite, and shortness of breath. She also had a cough productive of white sputum. Physical examination revealed an elevated jugular venous pressure, tachycardia, summation gallop, and pulmonary rales. No leg edema was noted. A clinical diagnosis of heart failure with pulmonary congestion was made. Because of the post-partum state, a computed tomography scan of the chest was ordered to rule out pulmonary embolus. No pulmonary emboli were found, but perihilar congestion suggestive of left ventricular failure was noted.
Diagnosis
An echocardiogram revealed severely reduced left ventricular systolic function with an ejection fraction of 20%. There was a large, mobile, loculated mass attached to the posterior and inferolateral wall of the left ventricle. (Figures 1 and 2) The cystic nature of the mass was thought to be very unusual for a thrombus. However, the presence of severe systolic dysfunction increased the likelihood that the cystic structure was a thrombus. A diagnosis of postpartum cardiomyopathy with a left ventricular thrombus was made.
 |
| Figure 1. Apical 2-chamber view demonstrating the cystic thrombus attached to the inferior wall. |
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| Figure 2. Apical 4-chamber view demonstrating thrombus with cystic appearance. |
Patient management and outcome
Anticoagulation was begun with enoxaparin and warfarin while her cardiomyopathy was treated with lisinopril, carvedilol, digoxin, furosemide, and potassium. The patient's symptoms improved significantly with this management. A follow-up echocardiogram obtained 1 week later showed complete resolution of the thrombus and an improved ejection fraction of 45%. No embolic events were noted clinically.
Discussion
Mural thrombi are usually protuberant in the acute stage and become laminar with time. In the very early stages of clot formation, imbalance between thrombogenic and thrombolytic factors could result in an unusual cystic appearance. It has been proposed that thrombin-activatable fibrinolysis inhibitor stabilizes the exterior of the clot while the inner core is lysed by plasmin, resulting in cystic clots.7
Thrombus in the form of highly mobile membranes, disappearing with anticoagulant therapy, has been reported as well.8 It appears that certain morphologic features of thrombus (cystic lesions and membranous lesions as opposed to protuberant masses) might suggest that the thrombus is in its early stage of formation and help in predicting complete resolution with anticoagulant therapy.
The unusual appearance in this case tempted us to consider metastatic choriocarcinoma as a differential diagnosis.9 We ruled out choriocarcinoma with a negative human chorionic gonadotropin assay.
References
- Perez-Sanz TM, Fulquet E, Neilan TG, et al. A case report of a round cystic tumor in the left ventricular outflow tract. J Am Soc Echocardiogr. 2006;19(11):1402.e9-1402.e11.
- Kim HK, Kim YJ, Chang SA, et al. Cardiac papillary fibroelastoma manifested as a left ventricular cystic mass. Int J Cardiol. 2005;101(3):507-508.
- Ben-Hamda K, Maatouk F, Ben-Farhat M, et al. Eighteen-year experience with echinococcosus of the heart: clinical and echocardiographic features in 14 patients. Int Cardiol. 2003; 91(2-3):145-151.
- Araoz PA, Mulvagh SL, Tazelaar HD, et al. CT and MR imaging of benign primary cardiac neoplasms with echocardiographic correlation. Radiographics. 2000;20(5):1303-1319.
- Ibanez B, Marcos-Alberca P, Rey M, et al. Multicavitated left atrial myxoma mimicking a hydatid cyst. Eur J Echocardiogr. 2005;6(3):231-233.
- Izgi A, Kirma C, Mansuroglu D, et al. Giant cystic left atrial myxoma as a cause of secondary pulmonary hypertension. Echocardiography. 2005;22(1):49-50.
- Lavi N, Zelinger A, Silver M. Thrombotic "ghosts:" echocardiographic appearance of thrombi with hollow cores and implications regarding mechanism of spontaneous clot lysis. J Am Soc Echocardiogr. 2006;19(12):1530.e5-6.
- Quintana O, Guiliani MD, Macina G, Boal BH. Echocardiographic appearance of large left ventricular mural thrombi undergoing lysis. J Am Soc Echocardiogr. 1994;7(2):165-168.
- Bozaci EA, Taskin S, Gurkan O, et al. Intracavitary cardiac metastasis and pulmonary tumor emboli of choriocarcinoma: the first case diagnosed and treated without surgical intervention. Gynecol Oncol. 2005; 99(3):753-756.
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