Revealing The Etiology of A Left Ventricular Mass Using Cardiac Magnetic Resonance

Tarek M. Mousa, M.D.,  Gorgi Kozeski, D.O., M. Rizwan Khalid, M.D.,  Adrianne Mellos, M.D., F.A.C.C., Saji Abraham, M.D., F.A.C.C.,  Frank Messineo, M.D., F.A.C.C. Ola Akinboboye, M.D., F.A.C.C., M.B.A.

A 59-year-old female with history of breast and ovarian CA was being evaluated because of an incidentally noted left ventricular mass on a routine follow-up breast MRI. Transthoracic and transesophageal echocardiograms detected a large pedunculated LV mass, 6.4cm in the long axis and 2.4cm in the short axis, attached to the apex. Differential diagnosis for the mass included a thrombus, tumor (primary or secondary), or a hypertrophied papillary muscle.  Cardiac magnetic resonance (CMR) imaging has emerged as a new non-invasive cardiac imaging modality providing superior information to echocardiography in the evaluation of patients with a suspected intracardiac mass allowing for better tissue characterization. CMR demonstrated a large cylindrical mass attached to the apex, nearly iso-intense with the myocardium that does not thicken with systole. Inversion recovery imaging sequence confirmed the mass to be a thrombus. Delayed enhancement imaging showed an antero-lateral-apical scar consistent with distal left anterior descending (LAD) artery infarct of the anterior left ventricular wall. The patient had no history of a prior MI and had no previous ischemic cardiac work up and had a normal EKG. The formation of a large thrombus on top of a small apical infarct is presumably a result of a hypercoagulable state caused by her malignancy. Patient was started on anticoagulation with warfarin and a follow-up echo 3 months later showed dramatic reduction in the thrombus size to 1.6cm x 2.2cm. Left ventricular (LV) thrombus formation after a myocardial infarction occurs in up to 30% of patients. These are mostly seen with LV apical and anterior infarcts, and are associated with high risk of systemic embolization. Herein, we describe a case of an exceptionally large intracavitary thrombus overlying an apical infarct in a patient with a probable hypercoagulable state from ovarian CA. There was no proof for the presence of this apical infarct before the findings of the delayed enhancement images, which played a crucial role in making the diagnosis of the case and the underlying pathology.