Early Left Ventricular Thrombus Following Ventricular Fibrillation/Ventricular Tachycardia Electrical Storm
Ramez Alyacoub1, Sherif Elkattawy1, Shruti Jesani1
1Department of Internal Medicine, Rutgers NJMS/Trinitas Regional Medical Center, Elizabeth, NJ, USA.
Insights
Left ventricular thrombus (LVT) can form rapidly after myocardial infarction (MI) and ventricular fibrillation (VF) arrest, presenting a rare clinical challenge. Early detection and management are crucial for patients experiencing cardiac arrest and electrical storm.
Area of Science:
- Cardiology
- Cardiovascular Medicine
- Thrombosis Research
Background:
- Left ventricular thrombus (LVT) formation is a known complication of myocardial infarction (MI), typically developing days after the event.
- Arrhythmias like ventricular fibrillation (VF) can exacerbate LVT risk by causing cardiac stasis.
- Electrical storm, characterized by recurrent VT/VF, further increases thrombosis risk in the setting of MI.
Purpose of the Study:
- To report a rare case of early LVT formation following VF cardiac arrest secondary to anterolateral MI.
- To discuss the risk factors, mechanisms, and management of LVT in the acute phase of cardiac arrest.
- To highlight the unusual timing of LVT development in this specific clinical scenario.
Main Methods:
- Case report presentation of a patient with VF arrest and subsequent LVT.
- Echocardiogram used for LVT diagnosis.
- Literature review on LVT formation, risk factors, and treatment.
Main Results:
- A patient presented with VF cardiac arrest and electrical storm due to anterolateral MI.
- LVT was identified on echocardiogram post-arrest, despite being absent on initial presentation.
- This LVT formation occurred unusually early, within the acute phase of the arrest.
Conclusions:
- LVT typically forms 3-14 days post-MI, but can occur within 24 hours with concomitant VF arrest.
- Key risk factors include large anterior MI, low ejection fraction (<30-35%), LV aneurysm, and delayed revascularization.
- Diagnosis via echocardiography or cardiac MRI; treatment involves anticoagulation (3-6 months) with VKA or heparin.
Abstract:
Left ventricular thrombus (LVT) formation is a serious clinical complication of low-flow states that may be seen in an ischaemic, arrhythmic heart. While LVT formation has a poor prognosis, in the setting of myocardial infarction it is usually a result of post-infarct sequelae such as left ventricle aneurysms, and inflammatory changes from damaged tissue, with the LVT taking several days to form. Arrythmias such as ventricular tachycardia (VT) or ventricular fibrillation (VF) may also lead to thrombus formation, as they contribute to stasis due to decreased cardiac output. Large anterolateral myocardial infarctions can cause electrical or arrhythmic storm, characterized by more than three episodes of VT or VF in a 24-hour period. This prolonged state of dyskinesis further increases the risk of thrombosis, creating a compounding effect. Here, we report the case of a patient who had a VF cardiac arrest with electrical storm secondary to anterolateral myocardial infarction complicated with LVT formation found on echocardiogram after the cardiac arrest, which was absent on presentation. This thrombus formation occurred particularly early during the course of the patient's arrest, possibly due to the compounding factors increasing the risk of thrombosis. Herein, we discuss in detail the risk factors for LVT formation, its mechanism and management options. A review of the literature also shows that LVT formation in the acute phase of arrest, as seen in our patient, is rare.
Learning Points:
Left ventricular thrombus (LVT) formation occurs 3-14 days after myocardial infarction, but in the setting of concomitant ventricular fibrillation arrest, may occur within the first 24 hours.Risk factors for LVT formation include a large infarct, anterior/anterior apical infarction, decreased ejection fraction (particularly <30-35%), left ventricular aneurysm, and delayed time to revascularization.Although diagnosis is generally made on transthoracic echocardiography with intravenous contrast, cardiac MRI with contrast has better sensitivity and specificity.Treatment consists of anticoagulation with a vitamin K antagonist or heparin for 3-6 months with a repeat echocardiogram to confirm the thrombus has organized or resolved. Further trials are needed to assess the efficacy of direct oral anticoagulants.
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