Left Ventricular Thrombus Diagnosed by Point-of-care Ultrasonography.

42 Journal of Emergencies, Trauma, and Shock I 9:1 I Jan Mar 2016 Dear Editor, A 63-year-old male presented to our Emergency Department for complaints of slurred speech and weakness of left upper extremity since 1-week. He has a prior history of hypertension, chronic obstructive lung disease, hyperthyroidism, anterior myocardial infarction, ischemic cerebrovascular accident, and recurrent transient ischemic attacks. A previously obtained coronary angiography demonstrated a totally occluded left anterior descending coronary artery at its proximal portion and stent implantation in a different session. On admission, his vital signs were normal, and electrocardiography evaluation demonstrated pathologic Q waves in the V1-V4 leads. Routine laboratory testing revealed normal electrolyte levels, renal, and liver functions. His activated partial thromboplastin time and prothrombin time with international normalized ratio were elevated (35.6 s “24-35 s” and 34.9 s “11-17 s” with 3.27 s “0.8-1.2 s,” respectively) due to his Coumadin therapy. Cranial computed tomography without contrast agent was ordered and depicted old infarct areas in the regions of left occipital lobe with the posterior part of the left parietal lobe and also findings of acute infarction in the left parietal lobe and periventricular areas. Apical four chamber view point-of-care cardiac ultrasonography (POCUS) performed by the emergency physician (EP) using a Mindray M7® model ultrasound machine with a 3.6 mHz microconvex transducer (M7, Mindray Bio-medical Electronics Co., Shenzhen, China) revealed an enlarged left ventricle (LV), akinetic and aneurysmatic anterior wall, and a large, highly mobile pedunculated hypoechoic mass (1 cm × 2 cm) attached to the interventricular septum and LV apex junction, protruding the LV cavity [Figure 1]. Computerized tomography with contrast agent of the thorax revealed contrast filling defects in the same anatomical region of the LV cavity [Figure 2]. Cardiovascular surgery and neurology recommended an operational removal of the thrombus, but the patient refused the operation. He was discharged from the hospital with recommendations on anticoagulation and a follow-up plan. POCUS has evolved into a critical skill for the EP and has been utilized in a myriad of clinical