Recurrent Left Ventricular Thrombus After Reverse Remodeling in Ischemic Cardiomyopathy: Insights From 4D Flow MRI

Apical left ventricular thrombus in ischemic cardiomyopathy may recur even after reverse remodeling and apparent improvement in cardiac function.

We describe the case of a 48-year-old man who presented with exertional dyspnea. Evaluation revealed triple-vessel coronary artery disease, a left ventricular ejection fraction of 20%, and an apical thrombus. Treatment with guideline-directed medical therapy, warfarin, and percutaneous coronary intervention led to thrombus resolution and improved systolic function, with the ejection fraction increasing to 40%. However, 4-dimensional flow magnetic resonance imaging at 4-year follow-up demonstrated diminished diastolic vortex localized to the basal left ventricle, indicating reduced apical flow velocity. Despite improved systolic function, apical thrombus recurred.

This case demonstrates that structural and functional recovery does not eliminate thrombotic risk. Persistent apical flow abnormalities may create a prothrombotic environment, highlighting the importance of longitudinal flow assessment with advanced imaging such as 4-dimensional flow magnetic resonance imaging, particularly in patients with a prior thrombus.