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Postgrad Med J doi:10.1136/postgradmedj-2013-131933
  • Images in medicine

Quadri-chamber cardiac thrombi in alcoholic cardiomyopathy: a rare though ominous finding

  1. Cholenahally Nanjappa Manjunath
  1. Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka, India
  1. Correspondence to Dr Yadvinder Singh, Department of Cardiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bangalore, Karnataka 560069, India; dryadvinder{at}hotmail.com
  • Received 7 March 2013
  • Revised 24 April 2013
  • Accepted 30 April 2013
  • Published Online First 24 May 2013

Introduction

Alcoholic cardiomyopathy is a cause of reversible cardiomyopathy, in which long-term abuse of alcohol leads to ventricular dysfunction. Multiple mechanisms have been attributed to the development of alcoholic cardiomyopathy such as mitochondrial damage and oxidative stress, though coexistent nutritional deficiencies like thiamine deficiency, tobacco abuse and other comorbidities such as hypertension can contribute to ventricular dysfunction. Ventricular thrombus formation can occur secondary to akinesia or hypokinesia of the ventricular wall. We report a case of alcoholic cardiomyopathy with an alarming finding of thrombi in all cardiac chambers. Echocardiographic evidence of quadri-chamber intracardiac thrombi has rarely been described in the literature.

Case

A 48-year-old man with history of chronic alcoholism presented with progressive breathlessness of 1 year's duration. Cardiovascular examination showed sinus tachycardia and evidence of congestive cardiac failure. A transthoracic echocardiogram (TTE) showed dilated cardiac chambers, severe biventricular global dysfunction with an alarming finding of thrombi in all four chambers (figure 1A–C; see online supplementary video S1–S4). TTE showed a large ‘C’ shaped thrombus in the left ventricle, multiple clots in the right ventricular apex and two further clots attached to the roofs of the left and right atrium, respectively. Laboratory investigations, including thyroid function test, vasculitic and thrombophillic profile, were unremarkable. CT of the brain was normal, with no evidence of embolic infarction. After initial stabilisation, obstructive coronary artery disease was excluded using myocardial perfusion imaging. The cause of biventricular dysfunction was presumed to be alcoholic cardiomyopathy. The patient abstained from alcohol and continued to receive anticoagulation and anti-heart failure drugs. He was followed up closely as alcoholic cardiomyopathy is a reversible condition. The patient is doing well at the 6-week follow-up, with complete resolution of all thrombus and no evidence of embolism.

Figure 1

(A) Apical five-chamber view shows three large thrombi (white arrows): the first one is a large, C-shaped layered clot located at the left ventricular (LV) apex; the second and third thrombi are attached to roof of the left (LA) and right atrium (RA), respectively. (B) Parasternal long-axis view shows a large clot (white arrow) attached to the LV apex. (C) Apical modified four-chamber view shows multiple clots (white arrows) at the right ventricular (RV) apex.

The most common conditions predisposing to intracardiac thrombosis are myocardial infarction and dilated cardiomyopathy.1 ,2 Other uncommon conditions include myocarditis, vasculitis, non-compaction cardiomyopathy or hypercoagulable states,3 such as factor V Leiden mutation, protein S deficiency, protein C deficiency and antiphospholipid antibody syndrome. In our case, clinical diagnosis of alcoholic cardiomyopathy was considered after excluding these conditions, and the patient responded well to medical management. The presence of intracardiac thrombi in all chambers is an extremely rare finding, irrespective of the cause, and may be disastrous owing to fatal systemic or pulmonary embolic phenomenon. Multichamber cardiac thrombus formation is attributed to the low-flow cardiac output state. Anticoagulation is the mainstay of treatment together with optimal anti-heart failure drugs. Surgical thrombectomy can be considered for a large mobile thrombus with high risk of embolism, particularly if attempts at anticoagulation have failed. Though there are a few reports of multichamber cardiac thrombus in the literature,1 ,3 ,4 echocardiographic detection of quadri-chamber thrombi has rarely been described.

Conclusion

Timely identification and management of intracardiac thrombus in cardiomyopathy is of immense importance, as this condition may be fatal. Hypercoagulable states should be ruled out in any case of multichamber cardiac thrombi. It is important to rule out ischaemic heart disease and other causes before diagnosing alcoholic cardiomyopathy.

Footnotes

  • Contributors YS, VS, BS and RR: conceived, designed, carried out the analysis and drafted the manuscript. RSK and CNM: critically reviewed important intellectual content and made the final approval.

  • Competing interests None.

  • Patient consent Obtained.

  • Provenance and peer review Not commissioned; internally peer reviewed.

References