Correspondence

Multifocal Coronary Thromboembolism from a Left Ventricular Thrombus

N Engl J Med 1999; 341:1083-1084September 30, 1999

Article

To the Editor:

Acute myocardial infarction due to coronary thromboembolism from a left ventricular thrombus has been suspected in patients with dilated or aneurysmal left ventricles, but it has rarely been documented. In previous reports of acute myocardial infarction in the presence of widely patent coronary arteries, the infarction was attributed to thromboembolism1,2 or coronary spasm.3 In another report, coronary-artery thrombosis that was identified by angiography was suggested to have been caused by thromboembolism from an unidentified left ventricular clot.4 We describe a young patient with dilated cardiomyopathy and acute myocardial infarction who underwent emergency coronary catheterization; the procedure revealed embolized clot fragments in multiple branches of the left-coronary-artery system and a large left ventricular mural thrombus.

A 27-year-old man presented to the emergency department with severe substernal chest pain that had lasted one hour. The electrocardiogram showed normal sinus rhythm and ST-segment elevation greater than 2 mm in the inferior leads. The medications administered on admission included amlodipine, nitrate, digoxin, furosemide, and aspirin. The patient was referred for emergency cardiac catheterization.

The patient's medical history included hypertension, type 1 diabetes, morbid obesity, and obstructive sleep apnea. In 1997, he had received a diagnosis from another hospital of dilated cardiomyopathy and congestive heart failure (presumably due to hypertension). One year later, he presented with a non–Q-wave myocardial infarction. At that time, an echocardiogram revealed four-chamber cardiomyopathy, global hypokinesia, and an ejection fraction of less than 25 percent; the results of cardiac catheterization were unremarkable.

Selective left coronary angiography at our institution revealed abrupt occlusions of the distal left anterior descending artery and its first diagonal branch (Figure 1AFigure 1Thromboembolism in a Patient with a Left Ventricular Thrombus.) that were consistent with multifocal thromboembolism. Percutaneous balloon angioplasty of the apical left anterior descending artery and abciximab restored flow of grade 2 (according to the classification of the Thrombolysis in Myocardial Infarction [TIMI] trial) (Figure 1B). The first diagonal artery was probed, but the obstruction was distal and not amenable to angioplasty. Left ventriculography revealed severe left ventricular dysfunction and suggested the presence of an apical mural thrombus. Subsequent transesophageal echocardiography confirmed severely diminished ventricular function and the presence of a mural thrombus (Figure 1C) and excluded the possibility of right-to-left shunting. The patient subsequently completed the course of abciximab, which was taken to inhibit acute rethrombosis after percutaneous balloon angioplasty. The peak troponin I level was 17.9 ng per milliliter. The patient was discharged on day 5 with a medical regimen that included warfarin, aspirin, an angiotensin-converting–enzyme inhibitor, and digoxin. He has remained well for six months.

Gregory M. Lanza, M.D., Ph.D.
Brett J. Berman, M.D.
Megumi Taniuchi, M.D., Ph.D.
Washington University School of Medicine, St. Louis, MO 63110

4 References

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   Dear HD, Russell RO, Jones WB, Reeves TJ. Myocardial infarction in the absence of coronary occlusion. Am J Cardiol 1971;28:718-721
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   Moriuchi M, Saito S, Tamura Y, et al. Thromboembolism in an angiographically normal coronary artery. Am Heart J 1989;118:1065-1067
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   Vincent GM, Anderson JL, Marshall HW. Coronary spasm producing coronary thrombosis and myocardial infarction. N Engl J Med 1983;309:220-223
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   Maddoux GL, Goss JE, Ramo BW, et al. Left main coronary artery embolism: a case report. Cathet Cardiovasc Diagn 1987;13:394-397
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Citing Articles (3)

Citing Articles

1. 1

   ALEX G. ORTEGA-LOAYZA, GEORGE A. STOUFFER. (2008) Multivessel Acute Myocardial Infarction: Case Report and Review of the Literature. The American Journal of the Medical Sciences 335:5, 375-378
   CrossRef

2. 2

   Ertan Yetkin, Hasan Turhan, A. Riza Erbay, Yuksel Aksoy, Kubilay Senen. (2005) Increased thrombolysis in myocardial infarction frame count in patients with myocardial infarction and normal coronary arteriogram: a possible link between slow coronary flow and myocardial infarction. Atherosclerosis 181:1, 193-199
   CrossRef

3. 3

   Perera, Rohan, Noack, Sigrid, Dong, Weifeng, . (2000) Acute Myocardial Infarction Due to Septic Coronary Embolism. New England Journal of Medicine 342:13, 977-978
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