B52-13 The Clots That Wouldn’t Budge: Medication Noncompliance Leading to Calcified Thrombi and Hemodynamic Compromise

Abstract Thrombi are organized masses of blood constituents that form when hemostatic mechanisms are activated by normal or pathological provocation. Several factors lead to increased thrombus formation, including stasis, endothelial injury, and hypercoagulability. Calcified thrombi are rare, typically occurring in low-flow venous areas of the body, where chronic thrombi can undergo dystrophic calcification. In areas of high flow, such as in the left ventricle, it is exceedingly rare to observe a large calcified thrombus, especially one large enough to occlude the left ventricular outflow tract (LVOT). This was seen in our case of a 52-year-old female with chronic diastolic heart failure secondary to dilated cardiomyopathy and end stage renal disease (ESRD) who presented with complaints of chest pressure and progressive dyspnea. She reported medication noncompliance for a seven month period leading up to her presentation. The patient was admitted for a non-ST-elevation myocardial infarction and started on continuous heparin infusion after she was noted to have troponin elevation. An echocardiogram revealed large left ventricular masses attached to the posterior papillary muscle and anterior mitral leaflet, prolapsing into the LVOT, with a left ventricular ejection fraction of 35%. The following day, she developed monomorphic ventricular tachycardia and required intubation. Surgical intervention was deferred due to poor candidacy, and she was managed medically in the intensive care unit. After twelve days of heparin therapy, with no change in thrombus size, further imaging was done with cardiac computed tomography (CT) and positron emission tomography CT. Calcified thrombi were confirmed and noted to be complications of her ESRD. Thirty-seven days after her initial presentation, surgical excision removed two calcified thrombi from the left ventricle and one from the right atrium. Discerning thrombus composition and chronicity requires a proactive approach to imaging. In patients with risk factors for thrombus formation, broad assessment with cardiac imaging is essential. Our case underscores the importance in early imaging and intervention in patients with high embolic risk. Mobile left ventricular thrombi pose a risk for systemic and coronary embolization, while right atrial thrombi threaten pulmonary obstruction. The dynamic motion of near-occlusive intracardiac thrombi can precipitate flash pulmonary edema or ventricular arrhythmias, as seen in our case. With the risk of acute ischemia, mechanical irritation, or abrupt worsening of ventricular function, swift characterization of thrombi composition may guide early intervention and mitigate fatal complications. Especially, in selection of initial management to further escalate appropriate treatment. This abstract is funded by: None