Recurrent bilateral lower limb arterial embolism secondary to left ventricular thrombus in peripartum cardiomyopathy successfully treated with systemic streptokinase thrombolysis: a rare case report

Peripartum cardiomyopathy (PPCM) is an uncommon but potentially life-threatening form of heart failure occurring toward the end of pregnancy or during the months following delivery in women without pre-existing heart disease. Left ventricular systolic dysfunction predisposes patients to intracardiac thrombus formation and systemic thromboembolic complications, which are associated with significant morbidity and mortality. A 35-year-old multiparous woman presented shortly after spontaneous vaginal delivery of an intrauterine fetal demise with acute right lower-limb ischemia and heart failure. Transthoracic echocardiography demonstrated severe left ventricular systolic dysfunction (LVEF approximately 35%), severe functional mitral regurgitation, pulmonary hypertension, and a large left ventricular thrombus. She underwent urgent Fogarty embolectomy followed by therapeutic anticoagulation with unfractionated heparin and warfarin. Despite therapeutic anticoagulation (INR 2.0 and activated partial thromboplastin time approximately 90 seconds), she developed recurrent bilateral acute lower-limb ischemia five days later. Because of profound hemodynamic instability and prohibitive surgical risk, systemic streptokinase thrombolysis was administered. Repeat echocardiography performed immediately after thrombolysis demonstrated complete resolution of the left ventricular thrombus. Follow-up echocardiography one week later showed significant recovery of left ventricular systolic function (LVEF 45–50%), improvement of mitral regurgitation to mild-to-moderate, and reduction in pulmonary artery systolic pressure. This case highlights the importance of early recognition of thromboembolic complications in PPCM and demonstrates that systemic streptokinase thrombolysis may represent an effective life- and limb-saving therapeutic option in carefully selected patients when surgical or catheter-based interventions are not feasible.