Multiple Left Ventricular Apical Thrombi in Mild Acute Pancreatitis Despite Preserved Ventricular Function: A Case Report

Abstract

Left ventricular thrombus is most commonly associated with acute myocardial infarction, significant regional wall motion abnormalities, ventricular aneurysm, or severe left ventricular systolic dysfunction. Its occurrence in a patient with preserved ventricular function and no significant obstructive coronary artery disease is unusual. We report the case of a middle-aged patient who presented with mild acute pancreatitis and a mature pancreatic pseudocyst measuring 6.8×6.9×6.0 cm. During contrast- enhanced abdominal CT performed for evaluation of the pancreatic pathology, an incidental left ventricular apical filling defect was identified. Subsequent transthoracic echocardiography and cardiac magnetic resonance imaging confirmed multiple left ventricular apical thrombi, the largest measuring approximately 1.7 cm, despite a preserved left ventricular ejection fraction of 65% and absence of overt regional wall motion abnormality. Coronary angiography demonstrated non-obstructive coronary artery disease, with a 40% lesion in the left circumflex artery. A thrombophilia evaluation was non-contributory. In view of the known systemic prothrombotic effects of acute pancreatitis, pancreatic inflammation was considered a potential contributor to thrombus formation, although a direct causal relationship could not be established. The patient was treated with apixaban 5 mg twice daily following multidisciplinary cardiology and surgical assessment. Elective intervention for the pancreatic pseudocyst was deferred because of the competing thromboembolic and procedural bleeding risks. At 6-week follow-up, repeat echocardiography demonstrated partial regression of the thrombus without clinical evidence of systemic embolization. This case highlights an unusual association between acute pancreatitis and left ventricular thrombus formation in the absence of the conventional major cardiac substrates. It also emphasizes the importance of careful review of cardiac structures visible on abdominal cross-sectional imaging and the need for multidisciplinary decision-making when an intracardiac thrombus is identified in a patient requiring elective surgery.