Large left ventricular thrombus surgically resected in a patient with normal ejection: A case report

INTRODUCTION: A left ventricular thrombus is very rare in a patient with normal systolic function. We are reporting a case of left ventricular thrombus in a patient with an abnormal presentation and normal ejection fraction. PRESENTATION OF CASE: A 57-year-old female patient presented with severe epigastric and central abdominal pain associated with nausea, vomiting, constipation, and a decrease in appetite. Post-contrast abdominal computerized tomography (CT) scan revealed multiple splenic infarcts. On echocardiographic study, a huge hyperechogenic, mobile mass was seen attached to the septo-apical wall of the left ventricle measuring 20 mm × 40 mm. Magnetic resonance imaging (MRI) also showed transmural late gadolinium enhancement in the apex which is suggestive of small myocardial infarction in the distal left anterior descending territory. Coronary angiogram showed non-occluded coronaries. The patient was treated surgically due to the urgency of the situation and the high risk of embolization. DISCUSSION: Our patient was on both progesterone and high dose tofacitinib. It is hypothesised that patient most likely experienced asymptomatic myocardial injury with non-occluded coronaries (MINOCA) weeks prior to the presentation. Involvement of distal left anterior descending artery caused apical akinesia resulting in blood stasis. Accompanying subendocardial injury and hypercoagulable state, due to being on progesterone and tofacitinib, led to the formation of the left ventricular thrombus. CONCLUSION: Due to the serious outcomes associated with an untreated left ventricular thrombus, it is necessary to carefully assess all patients suffering from systemic embolism with echocardiogram. Assessing the left ventricular mass with MRI was crucial to understanding the nature of the mass. Size, mobility, and protruding nature where characteristics that warranted urgent surgical intervention due to the high risk of embolization. Finally, it is important to note that tofacitinib might be a new suspect for left ventricular clots.