Clinical Case 08—A challenging clinical case: acute limb ischemia as a presentation of a left ventricular thrombus in a patient with heart failure with reduced ejection fraction

A 57-year-old male with arterial hypertension, diabetes mellitus, ischemic heart disease and coronary bypass in 2018, was admitted to the hospital with a 1-day evolution of sudden pain of strong intensity in the lower right limb. On physical examination, lower right limb showed erythrocyanosis, multiple distal ulcers, absence of hair, distal coldness up to the level of the knee, capillary refill >5 seconds, with absence of pedal and popliteal pulses. Arterial echo-Doppler of the lower right limb was performed, which reported common femoral and superficial femoral arterial insufficiency, with no flow in the distal third of the femoral, popliteal, tibial, and peroneal arteries. AngioCT of the lower limbs reported bilateral chronic arterial insufficiency with no flow from the superficial femoral artery to the popliteal and anterior tibial arteries of the right leg. A transthoracic echocardiogram was performed, which reported dilated heart disease with a left ventricular ejection fraction of 16% and an apical thrombus in the left ventricle of approximately 1.2 cm × 4.1 cm. Anticoagulation with unfractionated heparin was started, and thrombectomy of the lower right limb was evaluated, with a high probability of amputation due to irreversibility of ischemia. However, due to a high probability of surgical complications, conservative management was decided. Due to Virchow’s triad, patients with ischemic heart disease and heart failure with reduced ejection fraction are at high risk of intraventricular thrombi and subsequent embolization; therefore, the use of prophylactic anticoagulation should be considered to prevent this type of complication despite the evidence is controversial. Figure 1

A. 3D reconstruction of AngioCT of the lower limbs, arterial phase, red arrow indicates occluded flow in the form of a pencil point in the proximal third of the right superficial femoral artery, suggesting arterial thombosis. B and C. 4C EchoTT with an image of a large, consolidated thrombus with well-defined edges in the apex attached to the wall running over the interventricular septum (green arrow).