A 62-year-old female with a past medical history of hypertension, hyperlipidemia, and tobacco use presented with left-sided chest pain with radiation to the left arm that started the night prior to admission. She was recently diagnosed with mild COVID-19 infection two weeks earlier and was treated conservatively as an outpatient. She, nor her family, has any history of coronary artery disease, heart failure, or any arrythmias. She was found to be tachycardic but with a regular rhythm and an otherwise normal physical exam.
Laboratory data was notable for an elevated troponin of 31.2 ng/ml (reference: < 0.028 ng/ml) and elevated aspartate aminotransferase of 177 U/L. Electrolytes and an arterial blood gas values were within normal range.
ECG demonstrated ST elevations in leads II, III, aVF as well as V3-V5 with ST depression in aVL (Fig. 1). With a diagnosis of anterior and inferior myocardial infarction, patient was taken emergently for a left heart catheterization (LHC).
LHC showed a thrombotic occlusion of the proximal subsection of the distal left anterior descending (LAD) coronary artery with evidence of organized thrombus, judged by the difficulty in passing a wire across (Fig. 2A, Video 1). Multiple balloon dilatations as well as multiple rounds of aspiration with a penumbra catheter were attempted and intracoronary eptifibatide was administered with restoration of TIMI 2 flow (Fig. 2B, Video 2). Given the presence of organized clot, decision was to treat medically. The patient otherwise had non-obstructive disease of the other coronaries. A LHC was repeated 2 days later to see if the thrombus had resolved and stent could be placed. However, there was still residual thrombus in the distal LAD, unchanged from prior study (Fig. 2C). As patient was chest pain free and hemodynamically stable, no further intervention was attempted. A transthoracic echocardiogram (TTE) was performed, demonstrating apical akinesis with left ventricular (LV) ejection fraction of 39% by Simpson’s biplane method, as well as multiple large, mobile LV thrombi with a maximum size of 2cm x 1.5cm (Fig. 3A-B, Videos 3–9).
With systolic dysfunction in the setting of STEMI, the patient was maintained on aspirin, ticagrelor, atorvastatin, metoprolol succinate, spironolactone, and losartan. She was additionally started on a heparin drip with bridge to warfarin in setting of multiple large LV thrombi. Given the size and number of thrombi and associated increased risk of stroke, cardiac surgery was consulted for potential surgical LV thrombus evacuation. Surgical intervention was not recommended due to high risk of complications in the setting of recent ACS, and plan was to continue medical management.
It was thought that the LAD as well as LV thrombi were secondary to the patient’s recent COVID infection. At time of discharge, aspirin was discontinued. Ticagrelor was to be continued for a year and warfarin for at least 3 months based on resolution of thrombi.
Our patient followed up with cardiology and had a repeat TTE 2 months after hospital discharge. This TTE showed that there was a large apical aneurysm of the LV but no evidence of any thrombi in the apex (Fig. 4, Videos 10–13). The ejection fraction was still low around 35%. Warfarin was continued at this time due to lack of contrast with the last TTE study, but discontinued 3.5 months later when a repeat TTE with contrast showed that the LV remained unchanged with no evidence of thrombi (Fig. 5, Videos 14–16).