Vanishing Left Ventricular Thrombi in Severe Aortic Stenosis with Dilated Cardiomyopathy

A 20-year-old male presented to our department with complaints of dyspnea on effort for six months. On clinical examination, he had a low volume slow rising pulse, blood pressure of 100/70 mmHg and a raised jugular venous pressure. Cardiovascular examination revealed a downward and outward shifted apical impulse with an ejection systolic murmur of grade IV/VI intensity heard best at the right second intercostal space radiating to both carotids. There were bilateral basilar fine crepitations in chest. Two dimensional transthoracic echocardiography (2D TTE) with color Doppler (Fig. 1, Supplementary movie 1, 2, and 3) showed dilatation of all four cardiac chambers, left ventricle (LV) ejection fraction of 25% and multiple large layered as well as non-layered thrombi in the LV cavity. Aortic valve (AV) was bicuspid with severe aortic stenosis having a peak velocity of 4.2 m/sec. Three dimensional transthoracic echocardiography (3D TTE) clearly showed various details of the multiple thrombi like size, shape, mobility, number, location as well as the internal echolucent areas within the thrombus suggestive of clot lysis (Fig. 2, Supplementary movie 4). Patient denied any form of surgical intervention and was started on oral anticoagulation with warfarin (target INR: 2.0--3.0) along with standard decongestive therapy. A review echocardiography after 8 weeks (Fig. 3) showed complete disappearance of the LV thrombi. LV ejection fraction was almost unchanged. Congenital bicuspid AV is present in about 1--2% of the population and is more common in males. Most bicuspid AV function normally until late in life, although a subset of patients present in childhood or adolescence. Severe aortic stenosis can occur due to the bicuspid AV and if not treated in time can lead to LV dilatation with poor ejection fraction, which in turn can lead to pulmonary hypertension and right ventricular dilatation and dysfunction. In patients with dilated cardiomyopathy, the reported LV thrombus is 10--30%. Non-invasive pISSN 1975-4612/ eISSN 2005-9655 Copyright © 2014 Korean Society of Echocardiography www.kse-jcu.org http://dx.doi.org/10.4250/jcu.2014.22.2.98