Left Ventricular Thrombus After Acute Decompensated Heart Failure in the Setting of Ischemic Cardiomyopathy

A 70-year-old male with a medical history significant for long-standing ischemic cardiomyopathy (ICM) and heart failure with reduced ejection fraction (HFrEF) was admitted to the hospital with shortness of breath (SOB) five days after an acute heart failure (HF) exacerbation. He had non-radiating chest pressure now at rest, but without evidence of an acute coronary syndrome (ACS). Diagnostic work-up on readmission included a transthoracic echocardiogram (TTE), which revealed worsening left ventricular (LV) systolic dysfunction with new wall motion abnormalities and an incidental echo density in the LV apex, suggestive of an LV thrombus. These findings were unseen on imaging 20 months prior. The patient was initiated on warfarin to be maintained for three months, and discharged in stable condition after optimization of his anginal symptoms. Cardiac catheterization was not attempted secondary to the patient’s chronic kidney disease (CKD). The incidental finding of an LV thrombus occurred despite compliance with guideline-directed medical therapy of HFrEF and ICM, including adjunctive use of clopidogrel. With the poor survival associated with thromboembolism, the prevention, risk stratification and appropriate therapeutic approach to LV thrombus are poorly delineated in patients with HFrEF in sinus rhythm. Currently, the screening guidelines for the identification of LV thrombus in patients with HFrEF are also unknown. Given mixed evidence regarding prophylactic anticoagulation, we present this case of an incidental LV thrombus found during an episode of acute decompensated HF in the setting of long-standing ICM to emphasize the need to suspect LV thrombus formation after such presentations with closer follow-up for prompt detection and timely treatment.