The New England Journal of MedicineLeft Ventricular Thrombus after Anterior Myocardial Infarction

Management of Left Ventricular Thrombus in Late-Presenting Anteroseptal Myocardial Infarction: Practical Considerations and Clinical Implications

A 70-year-old woman with diabetes mellitus presented with a 3-day history of epigastric pain and vomiting, leading to the diagnosis of a transmural anteroseptal myocardial infarction complicated by a left ventricular thrombus. Despite the advances in reperfusion strategies, late presentation and atypical symptoms can still result in significant complications, necessitating careful evaluation and management. This case illustrates the importance of recognizing late-presenting myocardial infarction and its potential complications, and underscores the need for timely and appropriate medical therapy.

Key Points:

• Patient Presentation:
  • 70-year-old woman with diabetes mellitus.
  • 3-day history of epigastric pain and vomiting.
  • Electrocardiogram showed normal sinus rhythm with pathologic Q waves and T-wave inversions in the anterior leads.
  • High-sensitivity troponin level: 686 ng per liter (reference value, <11).
• Initial Assessment:
  • Transferred to a tertiary care hospital after symptoms resolved.
  • Coronary angiography identified complete occlusion of the mid–left anterior descending (LAD) artery.
  • Left ventriculography showed regional wall-motion abnormalities and a filling defect at the apex.
• Diagnostic Imaging:
  • Left ventriculography indicated a filling defect at the apex.
  • Transthoracic echocardiography showed a left ventricular ejection fraction of 37% and a mural thrombus.
• Diagnosis:
  • Transmural anteroseptal myocardial infarction complicated by a left ventricular thrombus.
• Management and Treatment:
  • Revascularization was not pursued due to delayed presentation and nonviable myocardium in the LAD territory.
  • Initiated guideline-directed medical therapy and therapeutic anticoagulation.
  • Regular outpatient follow-up was arranged.

HCN Medical Memo
This case highlights the critical importance of timely recognition and management of myocardial infarction, especially in patients presenting with atypical symptoms. Despite advances in reperfusion strategies, left ventricular thrombus remains a significant risk in late-presenting cases, necessitating vigilant evaluation and appropriate medical therapy to prevent complications.

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