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Obstructive endocardial thrombosis in endomyocardial fibrosis
  1. C Rost,
  2. S Bachmann,
  3. F A Flachskampf
  1. Correspondence to Dr C Rost; rost.christian{at}

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A 56-year-old woman presented with acute dyspnoea and oedema of the legs. As pre-existing condition, she had a stable rheumatoid arthritis under treatment with methotrexate and adalimumab.

Contrast-enhanced computed tomography of the chest did not demonstrate an acute pulmonary embolism or pulmonary oedema. Peripheral venous thrombosis was excluded by sonography.

Real-time three-dimensional (3D) echocardiography showed an extensive left and right ventricular thrombotic coating with predominance in the left ventricular apex (panel A1), leading to intracavitary obstruction (panel B). Multiple short-axis imaging based on the 3D dataset helped to delineate the obstruction and the full extent of the ventricular thrombi (panel C1). There were no echo signs of diastolic dysfunction (E/e'=9). Cranial magnetic resonance imaging and abdominal sonography showed no signs of an acute arterial embolism. The only notable laboratory finding was an eosinophilia (12% eosinophilic granulocytes, 7500/μl leucocytes). There were no history or other clinical signs of an allergic reaction or a parasite infection. Subsequent endomyocardial biopsy revealed minor myocardial fibrosis.

Panel A

Three-dimensional echocardiography demonstrates extensive endocardial thrombotic coating (1). Follow-up shows complete resolution of thrombi (2).

Panel B

Continuous wave Doppler echocardiographic examination shows an overlapping flow profile of the right ventricle/right atrium gradient and left ventricular apical flow acceleration caused by thrombotic lumen obstruction.

Panel C

Three-dimensional echocardiographic multiple short-axis imaging demonstrates circumferential apical thrombotic coating (1). Follow-up shows disappearance of apical lumen obstruction (2).

A diagnosis of early-stage endomyocardial fibrosis was made based on cardiac imaging, eosinophilia and biopsy findings. Medical therapy was started with therapeutic anticoagulation and high-dose steroids. The antirheumatic basis therapy was continued.

At 2-month follow-up, severity of symptoms had substantially improved. Echocardiographic examination revealed a complete resolution of thrombi and absence of intraventricular obstruction (panels A2 and C2).

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  • Competing interests None.

  • Patient consent Obtained.

  • Ethics approval This study was conducted with the approval of the case report.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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