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1 J Cardiol 2004 Dec; 446: Ampulla Cardiomyopathy With Left Ventricular Apical Mural Thrombi Resolved by Anticoagulant Therapy Without Systemic Complication: A Case Report Akira Hiroshi Takatoshi Takahiro Masayuki Takeo Hitoshi Masunori TAKAKI, MD OGAWA, MD WAKEYAMA, MD IWAMI, MD KIMURA, MD TANAKA, MD UCHINOUMI, MD MATSUZAKI, MD, FJCC Abstract A 79-year-old woman was admitted for treatment of bronchial asthma. ST-segment elevation in the precordial leads 4 6 and T-wave inversion in leads,, and af was recognized. Transthoracic echocardiography and emergent cardiac catheterization demonstrated two large mobile thrombi cm, cmattached to the left ventricular wall. There was no organic stenosis. Left ventriculography revealed anterolateral, apical and inferior dyskinesis, and basal hyperkinesis. The clinical diagnosis was ampulla cardiomyopathy. Anticoagulant therapy was started. Prothrombin time-international normalized ratio was remained at 2.53 and partial thromboplastin time was controlled at 1.52 times compared with the normal value. Repeated echocardiography showed the mass reduced gradually and had disappeared about 2 weeks later. J Cardiol 2004 Dec ; 446: Key Words Cardiomyopathies, other ampulla Echocardiography, transthoracic Anticoagulants Thrombosis left ventricular apical mural thrombi : ; Division of Cardiology, Tokuyama Central Hospital, Yamaguchi; Division of Cardiovascular Medicine, Department of Medical Bioregulation, Yamaguchi University School of Medicine, Yamaguchi Address for correspondence : TAKAKI A, MD, Division of Cardiology, Tokuyama Central Hospital, Koda-cho 11, Shunan, Yamaguchi ; [email protected] Manuscript received January 28, 2004 ; revised March 23 and April 26, 2004 ; accepted May 27,
2 244 Fig. 1 Serial electrocardiograms demonstrating changes in the ST segment and T wave A: On admission. B : After 7 days. C: After 28 days. 79 : : mg/day 450 mg/day mg : C : 156 cm40 kg36.8c 130/78mmHg98/min Fig. 1A: Fig. 2 Chest radiograph 98/minaF T 4 6 ST X Fig. 2: 53% J Cardiol 2004 Dec; 446:
3 245 Table 1: : cm0.71.0cm Fig. 3 Figs. 4AB Figs. 4CD 5 mmhg 2 mmhg4.82 l/min Table 1Laboratory findings on admission WBC 7,710/l RBC /l Hb 12.2 g/dl Ht 36.80% Plt /l TP 6.8 g/dl GOT 35 IU/l GPT 13 IU/l LDH 267 IU/l CRP 0.35 mg/dl BUN 15.0 mg/dl Cr 0.56 mg/dl Na/Cl 137/99 meq/l K 3.7 meq/l HbA 1C 4.90% Troponine 1.19 ng/ml Myoglobin 47 ng/ml CK-MB 5.1 ng/ml ANP 43.3 pg/ml BNP pg/ml Adrenaline 0.01 ng/ml Noradrenaline 0.17 ng/ml Dopamine 0.01 ng/ml 3 mg/day 10 4 U/day PT-INR2310% mg/day 250 mg/day 450 mg/day cm cm cm/sec cm Fig Fig. 3 D- Table 2 metaiodobenzylguanidine H/M % Fig. 528 Fig T Fig. 3 Transthoracic echocardiograms showing thrombi in the left ventricle Left: On admission : the thrombi were cm and cm. Middle: After 7 days: one thrombus had disappeared and the other was reduced to cm. Right : After 14 days: remaining thrombus was diminished. J Cardiol 2004 Dec; 446:
4 246 Fig. 4 Left and right coronary angiograms, left ventriculograms A: Left coronary angiogram showing no significant stenosis. B: Right coronary angiogram showing no significant stenosis. C, D : Left ventriculograms showing dyskinesis and a contrast defect on the apical wall due to thrombic: Diastole, D : Systole Table 2Levels of PT-INR, T-T and D-dimer PT-INR T-T% On admission D-dimerg/ml4.1 7th day th day th day Anticoagulant therapy was finished on the 28th day, so PT-INR and T-T were normalized. PT-INRprothrombin time-international normalized radio ; T-Tthrombo-test. Fig. 1C ST 3 J Cardiol 2004 Dec; 446:
5 247 Fig. 5 Iodine-123-metaiodobenzylguanidine cardiac scintigrams Defects were seen in the apical, lateral and inferior walls. A : Horizontal long axis. B : Vertical long axis. C: Short axis. D : Bulls eye map Na 43.2 pg/ml Na brain natriuretic peptide : BNP548.2 pg/ml BNP J Cardiol 2004 Dec; 446:
6 248 Fig. 6 Left ventriculograms taken 28 days later Normal contraction is shown. Left: Diastole. Right : Systole. 6 BNP 18 BNP pg/ml pg/ml BNP 45 mmhg 4 10 mg/day Vaiktus % % 14,15 1 J Cardiol 2004 Dec; 446:
7 249 D- D- 79 af T 4 6 ST cm cm J Cardiol 2004 Dec; 446: : spasm stunned myocardiumin : 1990; pp Shimizu M, Takahashi H, Fukatsu Y, Tatsumi K, Shima T, Miwa Y, Okada T, Fujita M : Reversible left ventricular dysfunction manifesting as hyperkinesis of the basal and the apical areas with akinesis of the mid portion : A case report. J Cardiol 2003 ; 41 :285290in Jpn with Eng abstr 3Kurisu S, Sato H, Kawagoe T, Ishihara M, Shimatani Y, Nishioka K, Kono Y, Umemura T, Nakamura S : Takotsubo-like left ventricular dysfunction with ST-segment elevation : A novel cardiac syndrome mimicking acute myocardial infarction. Am Heart J 2002; 143: : Circ J 2003 ; 67Suppl : 779 abstr 5 : ; 31 : : : J Cardiol 2002 ; 40 Suppl: 198abstr 7 : 1 Circ J 2002 ; 66 Suppl: 913abstr 8Yasuga Y, Inoue M, Takeda Y, Kitazume R, Hayashi N, Nakagawa Y, Mitsusada N, Nojima Y, Sumitsuji S, Nagai Y: Tako-tsubo-like transient left ventricular dysfunction with apical thrombus formation : A case report. J Cardiol 2004; 43 :7580in Jpn with Eng abstr 9Vaiktus PT, Barnathan ES : Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: A meta-analysis. J Am Coll Cardiol 1993; 22 : Phares WS, Edwards JE, Burchell HB : Cardiac aneurysms : Clinicopathologic studies. Mayo Clin Proc 1953; 28 : Jordan RA, Miller RD, Edward JE, Parker RL: Thromboembolism in acute and in healed myocardial infarction: J Cardiol 2004 Dec; 446:
8 250 Intracardiac mural thrombosis. Circulation 1952; 6 :16 12Abrams DL, Edelist A, Luria NH, Miller AJ : Ventricular aneurysm : A reappraisal based on a study of sixty-five consecutive autopsied case. Circulation 1963 ; 27 : Dubnow MH, Burchell HB, Titus JL: Postinfarction ventricular aneurysm : A clinicomorphologic and electrocardiographic study of 80 cases. Am Heart J 1965: 70 : Kontny F, Dale J, Nesvold A, Lem P, Soberg T: Left ventricular thrombosis and arterial embolism in acute anterior myocardial infarction. J Intern Med 1993; 233: Simpson MT, Oberman A, Kouchoukos NT, Rogers WJ: Prevalence of mural thrombi and systemic embolization with left ventricular aneurysm: Effect of anticoagulation therapy. Chest 1980; 77 : J Cardiol 2004 Dec; 446:
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