Impact of acute left ventricular apical thrombus on cardioversion for atrial fibrillation

Abstract

Among patients undergoing cardioversion for atrial fibrillation, the presence of left ventricular thrombus is a relatively uncommon and challenging clinical dilemma. While left atrial appendage thrombus is a contraindication to cardioversion, there is paucity of data regarding the safety of cardioversion in with the presence of left ventricular apical thrombus. Also, thrombus characteristics such as protrusion and mobility on echocardiography are known risk factors for systemic embolism. In this article, we present a case highlighting the management of atrial fibrillation in the setting of left ventricular dysfunction, acute heart failure, and echocardiographic evidence of acute left ventricular apical thrombus.

Keywords: atrial fibrillation; cardioversion; embolism; thrombus.

FIGURE 1

Last available electrocardiogram (ECG) obtained 6 years prior to admission demonstrates sinus rhythm (arrows) with incomplete right bundle branch block (A). ECG obtained upon admission (B) reveals atrial flutter (arrows) with 2:1 atrioventricular (AV) block, rapid ventricular response, and a nonspecific T-wave abnormality in the anterolateral leads (V3–V6)

FIGURE 2

Last available posteroanterior (PA) chest film obtained 6 years prior to admission notes normal cardiac size and no evidence of pulmonary infiltrates (A). PA chest x-ray upon admission (B) notes interval development of diffuse hazy interstitial opacities predominately at the base, cardiomegaly, and pulmonary venous hypertension

FIGURE 3

Transesophageal echocardiogram (TEE) (A) with zoomed in view of left ventricular apex (B), demonstrating a protruding, mobile echo density suggestive of an acute thrombus