# Case Report: Extracorporeal membrane oxygenation in acute coronary syndrome: a rare case of massive left ventricular thrombus

## TL;DR

A 42-year-old man on VA-ECMO developed a massive heart blood clot despite anticoagulation, highlighting the risks and management challenges in such cases.

## Contribution

This case report highlights the rapid formation of a massive left ventricular thrombus in VA-ECMO patients and suggests improved anticoagulation and unloading strategies.

## Key findings

- A massive left ventricular thrombus formed within 14 hours despite therapeutic anticoagulation.
- The patient developed refractory multi-organ failure, leading to withdrawal of care.
- The case emphasizes the need for multimodal anticoagulation monitoring and advanced LV unloading strategies.

## Abstract

Left ventricular (LV) thrombus is a catastrophic complication during veno arterial-extracorporeal membrane oxygenation (VA-ECMO) support for cardiogenic shock, arising from a confluence of hemodynamic stasis, a prothrombotic state, and potential limitations of conventional anticoagulation monitoring.

A 42-year-old man with acute inferior-wall ST-elevation myocardial infarction developed refractory cardiogenic shock during percutaneous coronary intervention, necessitating VA-ECMO initiation. Dual antiplatelet therapy and systemic heparinization (targeting an activated partial thromboplastin time of 50–80 s) were maintained.

Despite therapeutic anticoagulation, serial echocardiography documented the formation of a massive LV thrombus occupying >90% of the cavity within a 14 h interval on the fourth day of ECMO support. The patient subsequently deteriorated into refractory multi-organ failure, leading to withdrawal of care.

This case underscores the rapidity and severity of LV thrombus formation in VA-ECMO patients with severe ventricular dysfunction. It highlights the critical need for proactive management, including multimodal anticoagulation monitoring and aggressive, individualized LV unloading strategies that may require escalation beyond intra-aortic balloon pump support to more direct decompression methods.