Suspected Endomyocardial Fibrosis With Extensive Left Ventricular Thrombus: A Diagnostic Dilemma

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Suspected endomyocardial fibrosis (EMF) with biventricular dysfunction and extensive left ventricular thrombus (n=1). Intervention: Guideline-directed heart failure medical therapy (sacubitril/valsartan, bisoprolol, spironolactone, dapagliflozin) and warfarin anticoagulation. Primary outcome: Resolution of left ventricular thrombus, change in systolic function, and clinical survival.

Q: What does this research mean for the field?

Endomyocardial fibrosis can present atypically with biventricular impairment and extensive left ventricular thrombus, presenting substantial diagnostic uncertainty when characteristic cardiovascular magnetic resonance findings cannot be confirmed histologically. Novelty: ClaimNovelty.INCREMENTAL. Consensus alignment: ConsensusAlignment.NEUTRAL.

Suria Mano Geran; Safiyyah Burhani; Shalu Sharma; Aye Thida Hline

doi:10.7759/cureus.119032

November 2, 2026CureusOpen Access

Suspected Endomyocardial Fibrosis With Extensive Left Ventricular Thrombus: A Diagnostic Dilemma

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Why the study?

Suspected endomyocardial fibrosis presents significant diagnostic and therapeutic challenges when characteristic imaging findings coexist with atypical features and definitive histological confirmation cannot be obtained.

Key Points

To describe the diagnostic and management challenges of suspected endomyocardial fibrosis presenting with biventricular dysfunction and a large left ventricular thrombus.
Clinical and diagnostic evaluation of a 64-year-old man presenting with biventricular impairment and a large left ventricular thrombus.
Workup included multimodality imaging with echocardiography and cardiac magnetic resonance, coronary computed tomography angiography, and extensive screening for autoimmune, infective, haematological, and eosinophilic disorders.
Cardiac magnetic resonance demonstrated left ventricular systolic impairment with an ejection fraction of 34% and an avascular thrombus occupying approximately one-third of the cavity.
Extensive systemic screening failed to identify secondary autoimmune or hypereosinophilic disorders, while endomyocardial biopsy could not be obtained.
Despite guideline-directed heart failure therapy and anticoagulation, the thrombus persisted at six months and the patient died within a year.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

P

Population

A 64-year-old male with suspected endomyocardial fibrosis, biventricular systolic dysfunction, persistent mild eosinophilia, and a 4.8 × 3.8 cm apical left ventricular thrombus followed for less than one year.

I

Intervention

Guideline-directed medical therapy for heart failure (sacubitril/valsartan, bisoprolol, spironolactone, and dapagliflozin) plus anticoagulation with warfarin (target INR 2-3) following bridging with low-molecular-weight heparin.

O

Outcome

Clinical course, left ventricular thrombus persistence at 6-month echocardiographic follow-up, and survival within 1 year.hard clinical

This case highlights the diagnostic and therapeutic complexity of suspected endomyocardial fibrosis presenting in a non-endemic setting with biventricular dysfunction and an extensive LV thrombus when histological confirmation via endomyocardial biopsy cannot be safely obtained.

Limitations

Single-patient case report
Histological confirmation via endomyocardial biopsy was not obtained because the patient did not attend the scheduled appointment and biopsy was considered unsafe in the presence of a large LV thrombus
Bone marrow biopsy to further evaluate IgG-kappa paraproteinaemia was deferred due to concerns about interrupting warfarin therapy
Diagnosis of endomyocardial fibrosis remained presumptive based on clinical presentation and cardiac MRI findings
Diagnosis of EMF remained presumptive as histological confirmation via endomyocardial biopsy could not be obtained (patient missed appointment and biopsy was considered unsafe due to large LV thrombus)
Bone marrow biopsy was deferred due to the risk of interrupting warfarin anticoagulation in the presence of a persistent LV thrombus
The extent to which the thrombus itself contributed directly to haemodynamic deterioration could not be established with certainty

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Implication

May not respond to standard therapy in suspected EMF with large thrombus; leaves open optimal management without biopsy in non-endemic cases.

Abstract

We report a case of a 64-year-old man with biventricular dysfunction and a large left ventricular (LV) thrombus in whom endomyocardial fibrosis (EMF) was suspected. Despite extensive evaluation for eosinophilic, autoimmune, infective, and haematological causes, no secondary aetiology was identified. He was managed with guideline-directed heart failure therapy and anticoagulation. His condition progressively deteriorated, and he died within a year, highlighting the diagnostic challenge of suspected EMF when characteristic imaging findings coexist with atypical features and definitive histological confirmation cannot be obtained, as well as the therapeutic challenges of this rare cardiomyopathy.

Discussion

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Cite This Study

Geran et al. (2026) conducted a case report in Suspected endomyocardial fibrosis (EMF) with biventricular dysfunction and extensive left ventricular thrombus (n=1). Guideline-directed heart failure medical therapy (sacubitril/valsartan, bisoprolol, spironolactone, dapagliflozin) and warfarin anticoagulation was evaluated on Resolution of left ventricular thrombus, change in systolic function, and clinical survival.

synapsesocial.com/papers/6aeb344d5067c4e4a3d6992b https://doi.org/10.7759/cureus.119032

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Suspected Endomyocardial Fibrosis With Extensive Left Ventricular Thrombus: A Diagnostic Dilemma

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Suspected Endomyocardial Fibrosis With Extensive Left Ventricular Thrombus: A Diagnostic Dilemma

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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