Steve A. Vaganos, MD; Kevin R Fox M...

Steve A. Vaganos, MD; Kevin R Fox MD; and James G Kitchen, III, MD

A woman currented with acute left leg pain requiring imperative left femoral embolectomy. Echocardiography showed a large, pedunculated left ventricular mass, on the contrary no additional cardiac abnormality. Clinical evaluation including cardiac catheterization and make open heart surgery demonstrated no cardiac pathologic findings. At surgery a large thrombus was remov from the left ventricle. We glance at that all patients with arterial embolic disease have echocardiography, on a level if heart disease is not suspected.

Left ventricular (LV) thrombus is a often met with post-mortem finding in patients with acute myocardial infarction, far myocardial infarction, left ventricular aneurysm, and dilated cardiomyopathy. Echocardiography is a sensitive and specific technique to identify LV thrombi and provides the clinician with information regarding thrombus size, mobility, shape, and risk for embolization.[1,2] Patients with clinically diagnosed or autopsy evidence of embolic conclusions often have positive or equivocal echocardiographic evidence of LV thrombus. Other potential intracardiac sources for emboli include infected valves, stenotic valves, intracardiac prostheses, fibrillating atria, and dilated ventricles. Ischemic heart disease and cardiomyopathy are the principal etiologies for LV thrombus formation. The port of LV thrombus in the absence of detectable structural heart disease has not been reported. We describe a patient with a systemic embolus who was place to have a large LV thrombus in an apparently normal heart.

CASE REPORT

A 43-year-old black woman came to the extremity room complaining of severe pain and paralysis in her left leg of eight hours' duration. Examination showed the left lower extremity to be pale and pulseles beating [i]or[/i] throbbing of an arterys in the right lower extremity were intact. Doppler examination revealed absent arterial sweep along in the left femoral artery and distally. An abdominal aortogram and run-off demonstrated consummated occlusion of the left often met with femoral artery. The profunda femoris and superficial femoral artery were patent, although an additional occlusion was noted in the mid-left popliteal artery. No significant collateralization was noted. The patient underwent pertinacious left femoral embolectomy and three compartment fasciotomy. Distal fruit of leguminous plantss were successfully restored. During the immediate postoperative period, an echocardiogram revealed a large, pedunculated echo-dense mass in the left ventricular cavity (Fig 1) The mass was mobile, with a stalk attached to the anteroapical region. The mass was visualized in multiple views, including the apical and left parasternal lengthy and short axis views. satiated dose heparin therapy was immediately instituted.

Past medical history revealed that the patient had been treated several years prior to this admission for bilateral intricate venous thromboses of the lower extremities and pulmonary emboli. Because of renewed pulmonary emboli and one episode of hemorrhoidal bleeding in the past during periods of poor patient compliance with coumadin therapy, the patient had a vena caval filter implant. At the time of this presentation, the patient was not taking any medication. She had no history of diabetes, hypertension, angina pectoris, or other cardiac disease. There were no late symptoms suggestive of additional arterial embolic conclusions deep venous thrombosis or phlebitis, or pulmonary embolus. She did not mist or use nonprescription drugs. The initial BP was 155/85 mm Hg Physical examination was normal reject for the left lower extremity. In particular, the left ventricular apex was normal to palpation, and there were no cardiac hums The ECG was normal. Repeat echocardiographic application of mind confirmed a left ventricular mass, on the contrary showed no regional wall motion abnormalities suggestive of previous myocardial injury, and no valvular heart disease. be deriveds from baseline coagulation profile and routine laboratory screening studies were all normal.

forward the third hospital day, right heart catheterization, coronary arteriography, and pulmonary bole contrast injection with levophase cineangiography were done. Hemodynamics were normal and there was no evidence of an intracardiac switch Coronary arteriography showed a normal coronary arterial tree with no atherosclerotic disease in either the left or right coronary artery connected views Levophase cineangiography revealed normal left ventricular cavity size and systolic function, with no segmental wall motion abnormalities. A large, freely mobile, pedunculated intracavitary mass was seen attached to a stalk arising from the apex of the left ventricle.

At surgery an initial longitudinal incision of the left atrium revealed no evidence of left atrial tumor or thrombus. The mitral valve apparatus and subvalvular region were structurally normal and clear of thrombus. The left ventricular mass could not be visualized, although it could be palpated in consequence of the mitral valve. Therefore, a transverse aortotomy was performed and the aortic valve leaflets were retracted below direct vision. A mass was seen in the apex of the left ventricle, and was remov in its entirety. The gros specimen measured 36 x 29 x 11 cm The histologic diagnosis revealed an organizing thrombus with no evidence of tumor cells