PB0268 - Aortic Thrombosis Presenting as Myocardial Infarction in a Child

Sunday, July 10, 2022

6:30 PM – 7:30 PM

Location: Exhibition

Presentation Format: In-Person

Presenting Author(s)

Kristen Nelson McMillan, MD

Dir, Ped mechanical circulatory support; Ped cardiac critical care and heart failure
Chicagoland Children's Health Alliance
Valparaiso, Indiana, United States

Co-Author(s)

DP

Dhaval Patel

Pediatric interventional cardiologist
Advocate Children's Heart Institute
Oak Lawn, Illinois, United States
NI

Nobuyuki Ikeda

Pediatric cardiology fellow
Advocate Children's Heart Institute
Oak Lawn, Illinois, United States
SK

Sarah Kane

Pediatric DNP, Pediatric Heart Failure
Advocate Children's Heart Institute
Oak Lawn, Illinois, United States
CK

Chelsea Kriesberg

APRN, Pediatric Heart Failure
Advocate Children's Heart Institute
Oak Lawn, Illinois, United States
VD

Vince Dorsey

Pharm D, Pediatric Cardiac Critical Care
Advocate Children's Heart Institute
Oak Lawn, Illinois, United States
FY

Faeeq Yousaf

Pediatric pharmacist, Pharm D
Advocate Children's Hospital
Oak Lawn, Illinois, United States
NH

Narutoshi Hibino

Pediatric cardiothoracic surgeon
Chicagoland Children's Health Alliance
Oak Lawn, Illinois, United States
CE

Chawki ElZein

Pediatric cardiothoracic surgeon
Chicagoland Children's Health Alliance
Oak Lawn, Illinois, United States
LV

Luca Vricella

Chief, Pediatric Cardiothoracic Surgery; Co-Director of Pediatric Heart Institute
Chicagoland Children's Health Alliance
Oak Lawn, Illinois, United States

Background: Ascending aortic thrombus is rare in children without history of trauma, hypercoagulable condition or vascular disease and carries a high mortality risk necessitating rapid identification and management.

Aims: We aim to present the clinical course for a rare pediatric case.

Methods: We reviewed the medical record for a child with recurrent life-threatening thrombi.

Results: A 12-year old previously healthy male presented with chest pain. ECG revealed ST segment elevation. Echocardiography revealed an ejection fraction of 25% and a mobile mass (10 x 20 mm) in the ascending aorta. COVID testing was negative. Troponin-I was elevated. He was emergently placed on cardiopulmonary bypass where a large organized thrombus was removed. The left anterior descending coronary artery was occluded. He underwent intracoronary tPA, aspiration thrombectomy and balloon angioplasty. Hypercoagulable and autoimmune work-up revealed elevated factor 8 activity, von willebrand factor (vWF) activity and thrombocytosis with increased function by viscoelastic testing (ROTEM). Myocarditis, cardiogenetics and genetic testing for thrombophilia were negative. He was discharged on heart failure therapy, triple anti-platelet therapy (aspirin, clopidogrel, dipyridamole) and apixiban. He underwent a heart transplant 5 months later. Three weeks post-transplantion, he was incidentally found to have a large left atrial thrombus. At this time, he was only on aspirin. Factor 8 activity at time of transplant and second thrombus discovery was >400%. vWF activity and platelet count were also elevated. ROTEM revealed elevated platelet and fibrinogen activity. He underwent left atrial thrombectomy and was restarted on triple antiplatelet therapy and apixiban. He has not had recurrence on this regimen for 8 months.

Conclusion(s): Thrombocytosis and elevated pro-inflammatory coagulation factors may predispose to development of potentially fatal thrombi. Besides inflammation, etiology may be unknown, particularly in apparently healthy children, prompting additional research into potentially genetic conditions in these complex pathways to further elucidate patients at risk.