Heart transplant in a patient with acute onset of heart failure and massive bi-ventricular thrombi: A case report

Massive biventricular thrombi are a rare but serious complication of acute heart failure with reduced ejection fraction, presenting significant challenges in management. These thrombi can cause coronary thrombi leading to hemodynamic instability and raise the risk of systemic embolism. A 42-year-old male with a past medical history of type 2 diabetes mellitus presented with cardiogenic shock and pulmonary embolism. He was found to have new onset of heart failure with left ventricular ejection fraction of 15 % and harboring large biventricular thrombi. Stress test showed over 50 % of his myocardium was infarcted. Due to these findings, after a multidisciplinary team discussion, he was placed on veno-arterial extracorporeal membrane oxygenation (VA-ECMO) as bridge to orthotopic heart transplant (OHT), for hemodynamic support and prevention of distal embolization. He subsequently underwent OHT as an INTERMACS category 1 a few days later. This rare and complicated case highlights the importance of a multidisciplinary team approach, and utilization of VA-ECMO in an end-stage cardiomyopathy patient with large biventricular thrombi as bridge to OHT.

Learning objective

Veno-arterial extracorporeal membrane oxygenation can be utilized to prevent systemic embolization as a bridge to orthotopic heart transplant in patients with biventricular thrombus and end-stage cardiomyopathy.

Heart transplant can be a lifesaving treatment in a patient with biventricular thrombi and extensive non-viable myocardium.