Apical Thrombus Mimicking Ventricular Septal Rupture

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A 51-year-old man with chest pain was admitted to the emergency department. The patient was taken to the coronary angiography lab with a diagnosis of inferior myocardial infarction. The right coronary artery (RCA) was found to be totally occluded. A drug-eluting stent was implanted, and revascularization was achieved (Figure 1A and B). Post-procedure echocardiography (ECHO) showed a suspicious appearance consistent with ventricular septal rupture in the apical septum region (Figure 1C and D; Video). The patient was hemodynamically stable and cardiac magnetic resonance imaging  (MRI) was performed. Cardiac MRI revealed aneurysmatic enlargement in the cardiac apical region and a 58 x 14-mm thrombus surrounding the wall of the aneurysm much like a rim (Figure 2A and B). The patient was administered warfarin, an oral vitamin K antagonist, and was anticoagulated. At 2-month follow-up, we performed a control cardiac MRI and determined that the thrombus had significantly regressed (Figure 2C and D).

Ventricular septal rupture (VSR) is a life-threatening mechanical complication of acute myocardial infarction and is associated with high mortality.^1,2 Although the frequency of primary percutaneous coronary intervention has increased, its incidence is still approximately 0.25% in cases with acute coronary syndrome.³ Although percutaneous closure devices offer alternative treatments, surgery remains the standard treatment for VSR after acute coronary syndrome.⁴ Left ventricular thrombus is common in patients with apical aneurysm and is a serious risk factor for cardioembolic stroke.⁵ It is very rare for left ventricular apical aneurysm and thrombus to mimic VSR. Transesophageal echocardiography or cardiac MRI can be used in the differential diagnosis. In our case, a differential diagnosis was made with cardiac MRI imaging. In addition, we began anticoagulant therapy, which was stated to be the gold standard in the treatment of left ventricular thrombus.⁶

Affiliations and Disclosures

From the Department of ¹Cardiology and ²Radiology, Trakya University Faculty of Medicine, Edirne, Turkey.

Informed consent statement: Informed consent was obtained from all individual participants included in the study, and patient consent was provided for publication of the images used herein.

Disclosures: The authors report no financial relationships or conflicts of interest regarding the content herein.

Address for correspondence: Cihan Öztürk, Trakya University Faculty of Medicine, Department of Cardiology, 22030 Balkan Yerleşkesi, Edirne, Turkey. Email: dr.cihanozturk@gmail.com

References

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2.         Crenshaw BS, Granger CB, Birnbaum Y, et al. Risk factors, angiographic patterns, and outcomes in patients with ventricular septal defect complicating acute myocardial infarction. Circulation. 2000;101(1):27-32. doi: 10.1161/01.cir.101.1.27

3.         Elbadawi A, Elgendy IY, Mahmoud K, et al. Temporal trends and outcomes of mechanical complications in patients with acute myocardial infarction. JACC Cardiovasc Interv. 2019;12(18):1825-1836. doi: 10.1016/j.jcin.2019.04.039

4.         Ronco D, Matteucci M, Kowalewski M, et al. Surgical treatment of postinfarction ventricular septal rupture. JAMA Netw Open. 2021;4(10):e2128309. doi: 10.1001/jamanetworkopen.2021.28309

5.         Lip G, Gibbs CR. Does heart failure confer a hypercoagulable state? Virchow's triad revisited. J Am Coll Cardiol. 1999;33(5):1424-1426. doi: 10.1016/s0735-1097(99)00033-9

6.         McCarthy CP, Vaduganathan M, McCarthy KJ, Januzzi JL, Bhatt DL, McEvoy JW. Left ventricular thrombus after acute myocardial infarction: screening, prevention, and treatment. JAMA cardiology. 2018;3(7):642-649. doi: 10.1001/jamacardio.2018.1086

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