RENAL INFARCTION: AN ACUTE COMPLICATION OF APICAL THROMBOSIS IN A PATIENT WITH STEMI

Abstract Introduction Left ventricular thrombosis (LVT) is a complication that can be found in up to 12% patients with anterior ST–elevation myocardial infarction (STEMI). Discussion We reported a case of a 50–years–old male referred to our department for chest pain and ischemic ECG abnormalities. At admission he was hemodynamically stable, complaining of angina. ECG showed sinus rhythm and ST–segment elevation in V1–V4 and Q waves in the anterior leads. Thus diagnosis of anterior STEMI was made and urgent coronary angiography was performed: left descending artery occlusion was treated with primary angioplasty. Laboratory tests pointed out high troponin levels (13124 ng/L, normal <14 ng/L). Transthoracic echocardiogram (TTE) showed severe LV dysfunction (ejection fraction 30%); akinesia of apex, septum, anterior and mid inferior segments and spontaneous echo contrast in LV. TTE performed 6 days later revealed two mobile thrombi (1.2 x 0.5 cm and 2,1 x 0,7 cm) in LV lateral and septal apex. Anticoagulant therapy with Warfarin was started and low–molecular weight heparin was administered until International Normalized Ratio (INR) value reached a therapeutic range. Moreover de–escalation of P2Y12 receptor inhibitor therapy (switch from ticagrelor to clopidogrel) was carried out. Few days later, because of flank pain and vomiting, an abdominal CT was performed. It showed two right renal infarcts. The following TTE revealed just the presence of the thrombus located in LV septal apex. After one week LVT was no longer detected at TTE and the patient was discharged to cardiac rehabilitation, continuing therapy with Vitamin K antagonists (VKA). Conclusions LVT may lead to systemic embolism and consequently, in some cases, to renal infarction. This case report proves the importance of serially evaluating, with TTE, STEMI patients, in particular when apex akinesia is known. Treatment of LVT is anticoagulant therapy, extended for 3–6 months, usually with VKA, with an target INR of 2,5. New ESC guidelines for acute coronary syndromes pave the way to the use of new oral anti–coagulants (NOAC), after results of a meta–analysis and studies conducted on Rivaroxaban. In our case, administration of NOAC was not taken into account due to Chronic Kidney Disease. In conclusion, the treatment of LVT is nowadays a challenge for cardiologists, given the lack of data and the unstable balance between the hemorrhagic and thrombotic risk related to STEMI patients.