CHEST Guidelines-Echocardiographic-Image-of-Left-Ventricular-Thromb

Echocardiographic-Image-of-Left-Ventricular-Thromb

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The document describes a clinical case of a 25-year-old woman who experienced COVID-19-related cardiogenic shock, which was complicated by ventricular tachycardia and pulmonary edema. She was treated with venoarterial extracorporeal membrane oxygenation (VA-ECMO) and an intra-aortic balloon pump (IABP) to support her cardiac functions. During her recovery, an isoechoic mass, identified as a thrombus, was discovered in the left ventricle (LV) by point-of-care ultrasound (POCUS).<br /><br />VA-ECMO is a lifesaving intervention in severe cardiogenic shock, but it can lead to complications such as increased left ventricular afterload, potentially causing intracardiac thrombosis (ICT). The case highlights that VA-ECMO-induced ICT differs from thrombus formation post-myocardial infarction due to prolonged aortic valve closure and blood stasis within a non-ejecting heart. <br /><br />Upon detecting the LV thrombus, the anticoagulation therapy's intensity was increased to prevent complications. The patient's thrombus resolved after management, which included the use of unfractionated heparin (UFH) during ECMO support followed by rivaroxaban after weaning from ECMO. The patient recovered without neurological deficits and was ultimately discharged.<br /><br />The case underlines the importance of regular POCUS in monitoring cardiac function and detecting thrombus formation during VA-ECMO support. It also emphasizes the need for proper management of anticoagulation therapy in the presence of thrombi, especially in contexts like COVID-19, which may enhance coagulation risks. Despite the severe nature of the presented conditions, appropriate interventions led to a successful outcome, demonstrating ECMO and related monitoring techniques' critical roles in managing refractory cardiogenic shock and its complications.

Keywords

COVID-19

cardiogenic shock

ventricular tachycardia

pulmonary edema

VA-ECMO

intra-aortic balloon pump

thrombus

POCUS

anticoagulation therapy

cardiac function monitoring