Ischemic stroke in a patient with floating thrombosis of the left ventricular aneurysm and complete atrioventricular block infected with a COVID-19: a case report

Left ventricular (LV) thrombosis is a common complication of heart failure with reduced LV ejection fraction and can be a source of systemic embolism. The material presents the case of a 76-year-old woman with a history of myocardial infarction, LV aneurysm, coronary bypass surgery, who was admitted to the hospital with ischemic vertebrobasilar stroke. One month prior to present hospitalization, the patient was admitted to the hospital with transient complete atrioventricular block, underwent coronary artery stenting for stable angina pectoris with a drug-eluting stent, and was subsequently diagnosed with coronavirus disease 2019 (COVID-19), which required further inpatient treatment. Despite dual antithrombotic therapy (antiplatelet+anticoagulant) taken after discharge from the hospital, the patient was diagnosed with a floating thrombus in the apical LV aneurysm. Recurrent conduction disorders (transient atrioventricular block) required temporary pacing until the thrombus elements floated, after which a dual-chamber pacemaker was implanted. The main feature of this case is the formation of a floating thrombus in the LV aneurysm  11 years after myocardial infarction against the background of COVID-19 and anticoagulant therapy with direct oral anticoagulants. At the moment, there is still no unique opinion on the choice of anticoagulant therapy in patients with COVID-19 and a complicated cardiovascular history. In such cases, the anticoagulant regimen should be determined by a multidisciplinary team, taking into account the risks of thrombosis and bleeding.

1. Lattuca B, Bouziri N, Kerneis M, et al. Antithrombotic therapy for patients with left ventricular mural Thrombus. J Am Coll Cardiol. 2020;75:1676-85. doi:10.1016/j.jacc.2020.01.057.

2. Glikson M, Nielsen J, Kronborg M, et al. 2021 ESC Guidelines on cardiac pacing and cardiac resynchronization therapy. Eur Heart J. 2021;42,35:3427-520. doi:10.1093/eurheartj/ehab364.

3. Ibanez B, James B, Agewall S, et al. 2017 ESC guidelines for the management of acute myocardial infarction in patients presenting with ST-segment elevation. Eur Heart J. 2018;39:119-77. doi:10.1093/eurheartj/ehx393.

4. Dalia T, Lahan S, Ranka S, et al. Warfarin versus direct oral anticoagulants for treating left ventricular thrombus: a systematic review and meta-analysis. Thrombosis J. 2021;19(1):7. doi:10.1186/s12959-021-00259-w.

5. Robinson A, Trankle C, Eubanks G, et al. Off-label Use of Direct Oral Anticoagulants Compared With Warfarin for Left Ventricular Thrombi. JAMA Cardiol. 2020;5(6):685-92. doi:10.1001/jamacardio.2020.0652.

6. Levi M, Thachil J, Iba T, et al. Coagulation abnormalities and thrombosis in patients with COVID-19. Lancet Haematol. 2020;7(6):e438-e440. doi:10.1016/S2352-3026(20)30145-9.

7. Patell R, Bogue T, Koshy A, et al. Postdischarge thrombosis and hemorrhage in patients with COVID-19. Blood. 2020;136(11):1342-6. doi:10.1182/blood.2020007938.

8. Schutgens R. DOAC in COVID-19: Yes or No? Hemasphere. 2020;5(1):e526. doi:10.1097/HS9.0000000000000526.