Recurrent intra-cardiac thrombosis-A unique presentation of prothrombin G20210 mutation

We report a 49-year-old female patient with recurrent large left ventricular thrombus on echocardiogram in an apparently normal heart and insignificant cardiac past medical history. She underwent an excision of the left ventricular mass, final biopsy on which proved it to be a thrombus. Postoperative anti-coagulation was initiated with enoxaparin and warfarin and the patient was followed up at a cardiology clinic 6 weeks later. A repeat trans-thoracic echocardiogram revealed a new mass arising from the left atrium. Considering the increased risk of repeat ventriculostomy, she was treated conservatively with her current management. During this time the patient's pro-thrombotic work-up revealed positive prothrombin G20210 mutation. A follow up trans-thoracic echocardiogram done 2 months later surprisingly revealed complete resolution of the intracardiac mass. Our patient had prothrombin G20210 mutation, an entity primarily known for deep venous thrombosis, which rarely causes intra-arterial thrombus, intra-cardiac being unreported. There are no established protocols for management of these cases. The rate of embolic episodes in mobile pedunculated thrombi is reported as high as 60%. Patients with prior embolism must be offered immediate surgery, especially if the thrombus is large with an irregular surface, pedunculated, and multiple in number. Aggressive anti-coagulation with close monitoring is essential.