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\begin{document}

\title{APICAL TROMBUS in a PATIENT WITH NORMAL LEFT VENTRICULAR SYSTOLIC
FUNCTION}



\author[1]{Hülya Çelik}%
\author[2]{Saide Aytekin}%
\affil[1]{American Hospital}%
\affil[2]{Koç University School of Medicine}%


\vspace{-1em}



  
  \date{May 25, 2024}


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\selectlanguage{english}
\begin{abstract}
A 54-year old male patient presented to the emergency department with a
painful right hand and diagnosed as right axillary artery occlusion with
color Doppler ultrasound. The further multi-modality cardiac imaging
tests showed an apical thrombus in left ventricle apex which does not
have any wall motion abnormalities.%
\end{abstract}%



\sloppy


\textbf{APICAL TROMBUS in a PATIENT WITH NORMAL LEFT VENTRICULAR
SYSTOLIC FUNCTION}

\selectlanguage{ngerman}\textbf{Hülya Gamze Çelik\textsuperscript{a} MD, Saide
Aytekin\textsuperscript{b} MD}

\textsuperscript{\textbf{a}} \textbf{Department of Cardiology, American
Hospital, Istanbul, Turkey}

\textsuperscript{\textbf{b}} \textbf{Department of Cardiology, Koç
University School of Medicine, Istanbul, Turkey}

\textbf{Correspondence}

\textbf{Hülya Gamze Çelik, Department of Cardiology, American Hospital,
Istanbul, Turkey}

\textbf{e-mail: gguremek@yahoo.com}

\textbf{Abstract}

A 54-year old male patient presented to the emergency department with a
painful right hand and diagnosed as right axillary artery occlusion with
color Doppler ultrasound. The further multi-modality cardiac imaging
tests showed an apical thrombus in left ventricle apex which does not
have any wall motion abnormalities.

\textbf{Clinical presentation}

A 54-year-old male patient presented to the emergency department with a
painful right hand which was pale and cold. The vital signs were 85
beats per minute of heart rate, 120/80 mmHg measured blood pressure, 20
breaths per minute of respiratory rate and 98\% of oxygen saturation in
room air. The physical examination findings of cardiovascular,
respiratory, and gastrointestinal systems were normal. Extremity
examinations showed right hand and forearm cold, pulseless and
hypoesthetic without loss of motor functions.

The color Doppler ultrasound of the right upper extremity were
performed, and acute long segment thrombosis of the axillary artery were
detected. Biochemical tests were normal other than high glucose and
D-Dimer test results. Electrocardiogram showed normal sinus rhythm with
complete right bundle branch block and left anterior fascicular block,
normal PR and QTc intervals and no ischemic changes of ST-T segments
(Figure 1).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure 1 -} Electrocardiogram

The brachial thrombectomy under the guidance of ultrasound signing was
performed urgently and successful distal flow observed.

The patient has had a sarcoma excision from his right hip and diagnosed
with metastatic sarcomas in the lungs and has had the last surgery for
one of these masses with video-assisted thoracic surgery (VATS) 7 weeks
ago. He has never smoked, and alcohol consumption was social, and he
does not have a special medical history for clotting disorders.

Transthoracic echocardiography showed normal chamber sizes and valvular
functions, with the ejection fraction (EF) \%60 without wall motion
abnormalities. In the apical four and two chamber views, hyperechogenic
mass measured 1,32x1,05 cm was seen in the left ventricle's apex, and it
was commented to be a thrombus (Figure 2).\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image2/image2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image3/image3}

\end{center}
\end{figure}

\textbf{Figure 2} -- Thrombus in the LV apex in transthorasic
echocardiography

Since thrombus formation in the normal left ventricle is a very rare
condition, computerized tomography (CT) of the heart and coronary
arteries was done as a second imaging modality to verify the
intracardiac mass and see the coronary status for a possible
thrombectomy operation. The coronary arteries were normal (Figure 3),
and the thrombi were seen as a filling defect in the apex of the left
ventricle in the CT (Figure 4). In addition to the heart findings, there
were giant masses in the lungs which were interpreted as the sarcoma's
metastatic masses as described by the patient (Figure 5) .

The baseline biochemical tests did not show any hypercoagulable state,
further tests as protein C, S, Factor V Leiden mutations, glycoprotein
immunoglobulin antibodies, anticardiolipin antibodies could not be done
because of the patient's non-collaborative status. Lung sarcoma was
accepted as the underlying reason of the spontaneous thrombus in the
left ventricle.\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image4/image4}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image5/image5}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image6/image6}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image7/image7}

\end{center}
\end{figure}

\textbf{Figure 3 (A, B, C, D)} -- Normal coronary arteries as A-B: Left
anterior descending artery (LAD) , C: Circumflex artery (Cx) and D:Right
Coronary Artery (RCA)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image8/image8}

\end{center}
\end{figure}

\textbf{Figure 4:} Intraventricular filling defect in apical area (shown
with white arrows)\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image9/image9}

\end{center}
\end{figure}

\textbf{Figure 5:} Metastatic masses of the sarcoma (shown with red
arrows)

Because a thrombus located in the left ventricle with normal systolic
functions is more likely to embolize, the patient was recommended a
thrombectomy operation by the cardiovascular surgeon. The patient
refused to have the surgery and asked for medical therapy instead.
Because of the recent surgical operation he had, enoxaparin 6000 IU
twice daily was ordered, and the patient was discharged at his own
request to come for a follow-up one week later. However, it was learned
that he was hospitalized in another hospital with ischemic
cerebrovascular attack two days after discharge.

\textbf{Discussion}

Left ventricular thrombus with normal systolic functions is a very rare
condition. Only 31 cases were reported with male predominance (\%58)
(1). The predisposing factors are inflammatory conditions, malignancies,
blood dyscrasias, hypercoagulable states as lupus anticoagulant and
diagnostic work-up for these situations are advised (1). The apex of the
left ventricle is the most common site of thrombus in the ischemic and
non-ischemic myocardium and although there are no guidelines or
recommendation reports for the treatment of left ventricular thrombus in
patients with normal systolic functions, anticoagulation therapies with
or without surgical removal is recommended for these patients. The
anticoagulation algorithms advised for intracardiac thrombus in the
reduced left ventricle functions might be used. As the United States
guidelines recommend the usage of a vitamin K antagonist with a target
level of INR between 2.0-2.5 or dabigatran, rivaroxaban or apixaban for
3 months, European guidelines recommend the treatment up to 6 months
(2-6).

\textbf{Conclusion}

Patients with chronical inflammatory conditions, malignancies, blood
dyscrasias, hypercoagulable states as lupus anticoagulant have the
potential of intracardiac thrombus even if it is a rare condition in
normal LV systolic function. Regular follow-up of these patients with
echocardiography may ensure that the thrombus is detected without
embolism. Surgical procedures supported with anticoagulant treatments
appears to be beneficial in current practice.

\textbf{Funding}

This submission is not supported by external funding.

\textbf{Disclosures}

The authors have no relevant financial or non-financial conflicts of
interest to disclose.

\textbf{ORCID:} H\selectlanguage{ngerman}ülya Gamze Çelik MD:
https://orcid.org/0000-0001-6883-3197

Saide Aytekin MD: https://orcid.org/000-0003-1968-0889

\textbf{References}

\begin{enumerate}
\tightlist
\item
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\item
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\item
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\item
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\end{enumerate}

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