Associazione Nazionale Medici Cardiologi Ospedalieri



Incidental diagnosis of massive mobile left ventricle thrombi following COVID-19 infection in a heart failure patient

Mapelli Massimo Milano (Milano) – Centro Cardiologico Monzino, Irccs, Milano | Celeste Fabrizio Milano (Milano) – Centro Cardiologico Monzino, Irccs, Milano | Conte Edoardo Milano (Milano) – Centro Cardiologico Monzino, Irccs, Milano | Palermo Pietro Milano (Milano) – Centro Cardiologico Monzino, Irccs, Milano | Mancini Elisabetta Milano (Milano) – Centro Cardiologico Monzino, Irccs, Milano | Maiolo Giulia Milano (Milano) – Centro Cardiologico Monzino, Irccs, Milano | Ghulam Ali Sarah Milano (Milano) – Centro Cardiologico Monzino, Irccs, Milano | Agostoni Piergiuseppe Milano (Milano) – Centro Cardiologico Monzino, Irccs, Milano

Background: Intracardiac thrombus can be a complication of ischemic heart disease and cardiomyopathies. The advancements in imaging modalities have increased the capacity to diagnose this condition helping to reduce the associated complications (i.e. embolization). Previous reports suggest a possible link between intracardiac thrombosis and COVID-19 infection, especially in patients with severe “endotheliitis”, pneumonia, or myocarditis. COVID-19 effects on the cardiovascular system are partly evaluated. Venous and arterial thrombosis is commonly associated with COVID-19 but detection of intracardiac thrombus has not been frequently reported.

Case Description: A 71-year-old woman, known to have a non-ischemic dilated cardiomyopathy with reduced ejection fraction (EF) and a previous transcatheter edge-to-edge mitral valve repair (MitraClip), was admitted after a routine echocardiogram showing new onset multiple, highly mobile, left ventricle (LV) masses. The patient, fully vaccinated against Sars-Cov-2, experienced a paucisymptomatic COVID-19 infection 1 month before, followed by a full recovery. A transthoracic echocardiogram performed 3 months showed no LV masses. On admission she was completely asymptomatic with no clinical signs of heart failure or systemic embolization. A multimodality imaging evaluation (contrast echocardiography, cardiac computed tomography, cardiac magnetic resonance) confirmed a severe dilation of the LV with severe EF reduction, and 3 mobile LV masses. The largest mass was adhered to the middle portion of the anterolateral wall (maximum diameter 49×15 mm). A diagnostic endomyocardial biopsy and cardiac surgery were excluded due to prohibitive embolic/procedural risk and an anticoagulant treatment with warfarin was started with a progressive reduction of the masses’ dimension at transthoracic echocardiography. Thus, a diagnosis of exclusion of LV thrombosis was made. After 2-week a complete resolution of the masses was documented with no clinical or embolic events.

Conclusion: The pro-thrombotic nature of COVID-19 infection is well known. This case demonstrates how vulnerable patients, i.e. those with heart failure, may experience thrombotic complications following non-severe COVID-19 infection and despite having completed the vaccine course. Although currently unconfirmed by dedicated clinical trials, more assiduous echocardiographic monitoring and/or the use of anticoagulant therapies could yield a benefit in selected patients.