A 78-year-old man, who was an active smoker, presented with a 2-week history of chest pain, dyspnea and orthopnea. On examination, he was tachypneic and had bilateral basal crepitations. Chest X-ray showed bilateral alveolar edema, and blood tests revealed raised troponin and NT-proBNP. Electrocardiogram showed ST elevation in V1 to V5 and Q waves, compatible with acute pulmonary edema secondary to acute evolving anterior myocardial infarction. Transthoracic echocardiogram (figure 1, videos 1 and 2 of the supplementary data) showed a dilated left ventricle with a large dyskinetic apical region with a hyperechoic image within it (8×6 cm), indicative of intraventricular thrombus, and a left ventricular ejection fraction of 25%. Computed tomography (figure 2) showed a large apical thrombus in the left ventricle (3.1×6.2×9.6cm) occupying at least 50% of the cavity.

Figure 1

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Figure 2

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After finding some cases in the literature of intraventricular thrombus treated with direct oral anticoagulants (DOACs), the medical team decided to start anticoagulation with apixaban 5 mg/12h.

The patient progressed well. One month after discharge, repeat echocardiogram showed no thrombus but persistence of the large apical aneurysm with slow flow through it (figure 3, videos 3 and 4 of the supplementary data).

Figure 3

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Although the usual treatment is with heparin or vitamin K antagonists and there are no randomized clinical trials with DOACs, this case demonstrates the effectiveness of apixaban in resolving a large intraventricular thrombus in 6 weeks. Informed consent was obtained prior to publication.