Successful treatment of ball-shaped very late thrombus after myocardial infarction.

To cite: Inami T, Tsurumi M, Seino Y, et al. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/ bcr-2014-204340 DESCRIPTION A 40-year-old man presented with chest pain. Eight years ago he had suffered from acute anteroseptal ST-elevation myocardial infarction (MI) and 3 years ago he stopped taking medicines including antiplatelet drugs and warfarin by himself. ECG showed no ST-elevation this time; however, elevation of troponin Twas detected, which diagnosed a second attack of MI. Emergent coronary angiography showed total occlusion of previously deployed stent in the left ascending coronary artery. His conventional coronary risk factors were smoking and dyslipidaemia. Transthoracic echocardiography revealed a huge pedunculated, oscillating mass at the left ventricular (LV) apex (figure 1A, video 1), which had not been detected during the first admission. The echotexture is heterogeneous with pulsatile partial change of morphology. The size of the mass was 42×26 mm. Cardiac MRI also documented a mass at the apex (figure 1B). Three weeks after initiation of the recommended anticoagulant therapy including unfractionated heparin and warfarin, echocardiography showed the completely vanishing mass and none of apical aneurysmal changes (figure 1C, video 2). Differential diagnosis of ball-shaped mass in the LV may be thrombi, tumours or vegetations. Disappearance by anticoagulation therapy gave definitive diagnosis of thrombus. The incidence of LV thrombus was about 4% in patients with segment elevation MI (STEMI) treated with percutaneous intervention. Most of LV thrombi are mural thrombi