HFSA ePoster Library

Case Summary: A 49 year old with peripheral vascular disease presented to his vascular surgeon with leg pain and it was found cold and pulseless. He was diagnosed with critical limb ischemia and was directly admitted to the vascular surgery. CT found a femoral artery occlusion, cardiomegaly and bi-ventricular clots. Cardiology was consulted and a TTE noted bi-ventricular thrombi and a severely dilated LV with EF=20%. Palliative care was consulted. He was taken to the OR for BKA. Post-operatively he had a PEA arrest. He was in shock and given inotropes. Invasive hemodynamics, mechanical support, and coronary angiography were limited by renal failure, vascular access and thrombi. His shock improved, but he was not a candidate for advanced therapies. Coronary angiography showed multi-vessel disease. Cardiac MR showed viability in most regions but while awaiting revascularization, he became unresponsive. CT showed R ICA occlusion, R MCA occlusion, L M1 occlusion, and R watershed infarct. He was taken for mechanical thrombectomy. MRI showed multifocal infarcts in the L MCA, left pons, and left PCA. Fluids were trialed to improve perfusion, but he became hypoxic and repeat MRI did not show any improvement. He was unresponsive. The family enrolled the patient in hospice.
Discussion: Our patient had no history of HFrEF. While he had risk factors, symptoms were masked by severe peripheral vascular disease. Bi-ventricular thrombi are uncommon and place the patient at risk for systemic and pulmonary embolization. Aside from anticoagulation, there is little consensus on the management of intracardiac thrombi and the risk varies significantly within published data. In severe HF, complications and inability to tolerate GDMT should warrant advanced HF consultation. Early involvement of palliative care helped guide family during end of life care. More research is needed to better inform management options in heart failure complicated by intracardiac thrombi.