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Biventricular and Left Atrial Free Floating Thrombi in a Patient Diagnosed with Fulminant Myocarditis Managed with Thrombectomy and Left Ventricular Assist Device Implantation
ISSN: 2329-9517
Journal of Cardiovascular Diseases & Diagnosis
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Biventricular and Left Atrial Free Floating Thrombi in a Patient Diagnosed with Fulminant Myocarditis Managed with Thrombectomy and Left Ventricular Assist Device Implantation

Macit Kalçık1*, Mahmut Yesin1, M.Ozan Gursoy1, Lutfi Ocal1, Sinan Cerşit1 and Mehmet Ozkan1,2
1Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital, Istanbul, Turkey
2Department of Cardiology, Kars Kafkas University, Faculty of Medicine, Kars, Turkey
Corresponding Author : Macit Kalcik
Department of Cardiology, Kosuyolu Kartal Heart Training and Research Hospital
Esentepe Mah, Milangaz Caddesi Ünlüer Sitesi B-Blok No:22 Kartal /Istanbul, Turkey
Tel: (90)536 4921789
Fax: (90)216 4596321
E-mail: [email protected]
Received July 14, 2014; Accepted July 28, 2014; Published August 04, 2014
Citation: Kalçık M, Yesin M, Gursoy MO, Ocal L, Cerşit S, et al. (2014) Biventricular and Left Atrial Free Floating Thrombi in a Patient Diagnosed with Fulminant Myocarditis Managed with Thrombectomy and Left Ventricular Assist Device Implantation. J Cardiovasc Dis Diagn 2: 168. doi: 10.4172/2329-9517.1000168
Copyright: © 2014 Kalçık M, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Abstract

The majority of acute viral myocarditis cases are subclinical and self-limiting in both adults and children. However, acute fulminant myocarditis (AFM) has a fatal course due to the rapid development into acute heart failure, cardiogenic shock or serious arrhythmias. Cardiac thrombus formation is an important factor affecting the prognosis of these patients. We present a patient who was diagnosed as AFM with multiple free floating intracardiac thrombi and aimed to explore the clinical characteristics and the treatment of AFM.

Keywords
Myocarditis; Thrombus; Assist device; Echocardiography
Case Presentation
A previously healthy 18-year-old man was admitted to our hospital with cardiac decompensation after a flu-like disease 2 weeks earlier. The electrocardiogram displayed negative T-waves in anterior precordial leads with low valtage QRS complexes. Laboratory findings revealed leukocytosis (18x103/μL, 65% lymphocytes) and elevated blood levels of troponin I (2.5 ng/mL) (Normal < 0,05 ng/mL), C reactive protein: 38 mg/dL (Normal < 0,8 mg/dL), procalcitonin (11 mcg/mL) (Normal < 0,5 mcg/mL) and NT-proBNP (3100 pg/mL) (Normal <300 pg/mL). Physical examination revealed a heart rate of 115 bpm, respiratory rate of 21/min, blood pressure of 100/70 mmHg. Transthoracic echocardiography (TTE) revealed a globally hypokinetic and dilated left ventricle with an ejection fraction of 15% and multiple mobile thrombi in all heart chambers except right atrium (Figure 1). The septal wall thickness was measured as 15 mm and right ventricular systolic function was also diminished. There were not any signs of any other organ failure on admission. The patient underwent emergent surgery with thrombectomy and left ventricular assist device (LVAD) implantation without any thromboembolic events. Myocardial biopsy which was taken during surgery showed interstitial lymphocytic inflammation with scattered foci of myocyte necrosis which was consistent with acute fulminant myocarditis (AFM). Anti-inlammatory and immunosuppressive treatment with prednisolone (3*16 mg for 1 month), anticoagulation with intravenous unfractioned heparin followed by oral warfarin (for 3 months) and cardiac supportive treatment with ramipril (2.5 mg/day) and spironolactone (25 mg/ day) was performed. The treatment regimen included an intravenous inotrop (dopamine 5-15 mcg/kg/min) in the first two weeks in addition to LVAD. There was no side effects or complications related to the treatment. Weaning from LVAD support was achieved in the 4th week and he discharged from the hospital after 6 weeks. Two months after admission the patient’s general condition was good and TTE showed nearly normal left ventricular systolic functions with an ejection fraction of 50% (Videos 1 and 2).
Intracardiac thrombus formation is an important factor affecting the prognosis of AFM and emergent surgery has an incremental value for primary embolic prevention in these patients [1,2]. LVAD implantation may be used as a bridge to recovery from AFM [3].
References
  1. Ağaç MT, Akyüz AR, Acar Z, Erkan H, Vatan B (2011) Massive multi-chamber heart thrombosis as a consequence of acute fulminant myocarditis complicated with fatal ischaemic stroke. Eur J Echocardiogr 12: 885.

  2. Thuny F, Avierinos JF, Jop B, Tafanelli L, Renard S, et al. (2006) Images in cardiovascular medicine. Massive biventricular thrombosis as a consequence of myocarditis: findings from 2-dimensional and real-time 3-dimensional echocardiography. Circulation 113: e932-933.

  3. George CL , Ameduri RK, Reed RC, Dummer KB, Overman DM, et al. (2013) Long-term use of ventricular assist device as a bridge to recovery in acute fulminant myocarditis. Ann ThoracSurg 95: e59-60.

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