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.