A Case of Thrombus Development Inside a Left Ventricular Apical Aneurysm in Hypertrophic Cardiomyopathy with Midcavity Obstruction

Authors' Affiliations

Ashwin Jagadish, Medical Student, James H. Quillen College of Medicine, East Tennessee State University, Johnson City, TN Shobha Hiremagalur, Cardiology, Ballad Health CVA Heart Institute, Johnson City, TN Shahnawaz Notta, Department of Internal Medicine, East Tennessee State University, Johnson City, TN Ahmed Khan, Cardiology, Ballad Health CVA Heart Institute, Johnson City, TN

Location

D.P. Culp Center Ballroom

Start Date

4-5-2024 9:00 AM

End Date

4-5-2024 11:30 AM

Poster Number

60

Name of Project's Faculty Sponsor

Ahmed Khan

Faculty Sponsor's Department

Cardiology, Ballad Health CVA Heart Institute

Classification of First Author

Clinical Doctoral Student

Competition Type

Competitive

Type

Poster Presentation

Presentation Category

Health

Abstract or Artist's Statement

The prevalence of hypertrophic cardiomyopathy (HCM) is approximately 1:200-1:500. HCM most commonly affects either the anterior free wall or basal anterior septum, although any portion of the left ventricle may be involved. An uncommon type of HCM, midcavity left ventricular (LV) obstruction, is seen in close to 10% of cases. Approximately 5% of those with HCM develop LV apical aneurysms. Within such an aneurysm, a thrombus may form; depending on the study, the risk of thrombus formation may be 6.5% or 14%. There is a 2.03% annualized risk of having a thromboembolic stroke. Thrombus formation can occur in aneurysms of all sizes, and are typically evaluated using echocardiography. The size of a small aneurysm is less than 2 cm, while the size of a large aneurysm is more than 4 cm. The size of a medium aneurysm is between that of a small and large aneurysm. In the event that apical aneurysms or thrombus formation cannot be detected using echocardiography, cardiac magnetic resonance imaging or contrast echocardiography can be used. Roughly one-fifth of thromboembolic events and apical thrombus development were associated with small aneurysms. There can be a four-fold elevation in the risk of LV thrombus development when the aneurysm size is more than 2 cm. For those with aneurysms larger than 2 cm, prophylactic anticoagulation may be warranted. Anticoagulation has even been suggested for individuals who have had resolution of a thrombus inside an aneurysm that was 2 cm or larger. Options for anticoagulation include direct anticoagulation or medications that antagonize vitamin K. Surgical interventions can be utilized for alleviating obstruction, if necessary. A 76-year-old female with paroxysmal atrial fibrillation and midcavity LV hypertrophy with obstruction and LV apical aneurysm was evaluated in the cardiology clinic for a regular appointment. Previously, the patient declined treatment for the midcavity LV hypertrophy and LV apical aneurysm. Her most recent echocardiogram, completed 3.5 months before this appointment, did not demonstrate a thrombus within the LV apical aneurysm. She was taking warfarin for anticoagulation, but discontinued it eight weeks prior to the appointment due to gastrointestinal (GI) bleeding resulting in anemia and supratherapeutic prothrombin time-international normalized ratio (PT-INR). Her hemoglobin at the time of the GI bleed was 9.7 g/dL, hematocrit was 28.7%, and PT-INR was 9.5. Her baseline hemoglobin was 13.1 g/dL before the GI bleeding. After the clinic appointment, she underwent an echocardiogram which showed a thrombus within the LV apical aneurysm. The thrombus was confirmed using contrast echocardiography. The aneurysm was 3.8 x 4.05 cm. Her hemoglobin at the time of this echocardiogram was 14.7 g/dL and her hematocrit was 44.5%. She was advised to take 5 mg of apixaban orally every 12 hours. After three months, an echocardiogram revealed that the thrombus had completely resolved.

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Apr 5th, 9:00 AM Apr 5th, 11:30 AM

A Case of Thrombus Development Inside a Left Ventricular Apical Aneurysm in Hypertrophic Cardiomyopathy with Midcavity Obstruction

D.P. Culp Center Ballroom

The prevalence of hypertrophic cardiomyopathy (HCM) is approximately 1:200-1:500. HCM most commonly affects either the anterior free wall or basal anterior septum, although any portion of the left ventricle may be involved. An uncommon type of HCM, midcavity left ventricular (LV) obstruction, is seen in close to 10% of cases. Approximately 5% of those with HCM develop LV apical aneurysms. Within such an aneurysm, a thrombus may form; depending on the study, the risk of thrombus formation may be 6.5% or 14%. There is a 2.03% annualized risk of having a thromboembolic stroke. Thrombus formation can occur in aneurysms of all sizes, and are typically evaluated using echocardiography. The size of a small aneurysm is less than 2 cm, while the size of a large aneurysm is more than 4 cm. The size of a medium aneurysm is between that of a small and large aneurysm. In the event that apical aneurysms or thrombus formation cannot be detected using echocardiography, cardiac magnetic resonance imaging or contrast echocardiography can be used. Roughly one-fifth of thromboembolic events and apical thrombus development were associated with small aneurysms. There can be a four-fold elevation in the risk of LV thrombus development when the aneurysm size is more than 2 cm. For those with aneurysms larger than 2 cm, prophylactic anticoagulation may be warranted. Anticoagulation has even been suggested for individuals who have had resolution of a thrombus inside an aneurysm that was 2 cm or larger. Options for anticoagulation include direct anticoagulation or medications that antagonize vitamin K. Surgical interventions can be utilized for alleviating obstruction, if necessary. A 76-year-old female with paroxysmal atrial fibrillation and midcavity LV hypertrophy with obstruction and LV apical aneurysm was evaluated in the cardiology clinic for a regular appointment. Previously, the patient declined treatment for the midcavity LV hypertrophy and LV apical aneurysm. Her most recent echocardiogram, completed 3.5 months before this appointment, did not demonstrate a thrombus within the LV apical aneurysm. She was taking warfarin for anticoagulation, but discontinued it eight weeks prior to the appointment due to gastrointestinal (GI) bleeding resulting in anemia and supratherapeutic prothrombin time-international normalized ratio (PT-INR). Her hemoglobin at the time of the GI bleed was 9.7 g/dL, hematocrit was 28.7%, and PT-INR was 9.5. Her baseline hemoglobin was 13.1 g/dL before the GI bleeding. After the clinic appointment, she underwent an echocardiogram which showed a thrombus within the LV apical aneurysm. The thrombus was confirmed using contrast echocardiography. The aneurysm was 3.8 x 4.05 cm. Her hemoglobin at the time of this echocardiogram was 14.7 g/dL and her hematocrit was 44.5%. She was advised to take 5 mg of apixaban orally every 12 hours. After three months, an echocardiogram revealed that the thrombus had completely resolved.