CASE PRESENTATION
A 62-year-old female with a past medical history of hypertension,
hyperlipidemia, and tobacco use presented with left-sided chest pain
with radiation to the left arm that started the night prior to
admission. She was recently diagnosed with mild COVID-19 infection two
weeks earlier and was treated conservatively as an outpatient. She, nor
her family, has any history of coronary artery disease, heart failure,
or any arrythmias. She was found to be tachycardic but with a regular
rhythm and an otherwise normal physical exam.
Laboratory data was notable for an elevated troponin of 31.2 ng/ml
(reference: < 0.028 ng/ml) and elevated aspartate
aminotransferase of 177 U/L. Electrolytes and an arterial blood gas
values were within normal range.
ECG demonstrated ST elevations in leads II, III, aVF as well as V3-V5
with ST depression in aVL (Figure 1). With a diagnosis of anterior and
inferior myocardial infarction, patient was taken emergently for a left
heart catheterization (LHC).
LHC showed a thrombotic occlusion of the proximal subsection of the
distal left anterior descending (LAD) coronary artery with evidence of
organized thrombus, judged by the difficulty in passing a wire across
(Figure 2A, Video 1). Multiple balloon dilatations as well as multiple
rounds of aspiration with a penumbra catheter were attempted and
intracoronary eptifibatide was administered with restoration of TIMI 2
flow (Figure 2B, Video 2). Given the presence of organized clot,
decision was to treat medically. The patient otherwise had
non-obstructive disease of the other coronaries. A LHC was repeated 2
days later to see if the thrombus had resolved and stent could be
placed. However, there was still residual thrombus in the distal LAD,
unchanged from prior study (Figure 2C). As patient was chest pain free
and hemodynamically stable, no further intervention was attempted. A
transthoracic echocardiogram (TTE) was performed, demonstrating apical
akinesis with left ventricular (LV) ejection fraction of 39% by
Simpson’s biplane method, as well as multiple large, mobile LV thrombi
with a maximum size of 2cm x 1.5cm (Figure 3A-B, Videos 3-9).
With systolic dysfunction in the setting of STEMI, the patient was
maintained on aspirin, ticagrelor, atorvastatin, metoprolol succinate,
spironolactone, and losartan. She was additionally started on a heparin
drip with bridge to warfarin in setting of multiple large LV thrombi.
Given the size and number of thrombi and associated increased risk of
stroke, cardiac surgery was consulted for potential surgical LV thrombus
evacuation. Surgical intervention was not recommended due to high risk
of complications in the setting of recent ACS, and plan was to continue
medical management.
It was thought that the LAD as well as LV thrombi were secondary to the
patient’s recent COVID infection. At time of discharge, aspirin was
discontinued. Ticagrelor was to be continued for a year and warfarin for
at least 3 months based on resolution of thrombi.
Our patient followed up with cardiology and had a repeat TTE 2 months
after hospital discharge. This TTE showed that there was a large apical
aneurysm of the LV but no evidence of any thrombi in the apex (Figure 4,
Videos 10-13). The ejection fraction was still low around 35%. Warfarin
was continued at this time due to lack of contrast with the last TTE
study, but discontinued 3.5 months later when a repeat TTE with contrast
showed that the LV remained unchanged with no evidence of thrombi
(Figure 5, Videos 14-16).