Multiple intra-cavitary thrombi in a late-onset dilated cardiomyopathy with severely reduced ejection fraction: A case report and review of the literature.

BACKGROUND

Dilated cardiomyopathy is defined by left ventricular dilatation and systolic dysfunction and may rarely be complicated by left ventricular thrombi, which carry a significant risk of systemic embolization.

CASE PRESENTATION: A 77-year-old woman with dyslipidemia and depression presented with progressive dyspnea (NYHA IV) and palpitations. Transthoracic echocardiography revealed severe biventricular dysfunction (left ventricular ejection fraction 24%) and multiple partially mobile thrombi in the left ventricular. Coronary angiography excluded obstructive coronary artery disease, and cardiac magnetic resonance confirmed severe left ventricular dilatation, diffuse hypokinesia, extensive fibrosis, and thrombotic appositions. Secondary causes of dilated cardiomyopathy and thrombophilia were excluded; genetic testing revealed a heterozygous BAG3 variant.

MANAGEMENT: The patient was treated with intravenous diuretics, non-invasive ventilation, unfractionated heparin followed by apixaban, and guideline-directed medical therapy for heart failure, including a beta-blocker, angiotensin receptor-neprilysin inhibitor, MRA, and SGLT2 inhibitor. Serial imaging at 7 days showed a reduction of thrombotic burden, with complete resolution confirmed at 2-month follow-up.

OUTCOME: At 4-month follow-up, the patient was asymptomatic (NYHA I-II) with improved left ventricular ejection fraction (35%) and no documented arrhythmias. Given functional recovery and absence of significant conduction delay, device implantation was not indicated.

CONCLUSION

This case highlights the importance of early recognition and prompt anticoagulation in dilated cardiomyopathy complicated by left ventricular thrombi. A structured diagnostic and therapeutic strategy-integrating multimodality imaging, exclusion of secondary causes, and genetic assessment-can lead to complete thrombus resolution and favorable remodeling.