A 78-year-old male, hypertensive, ischemic heart disease patient with previous transthoracic echocardiography in 2015 showing dilated left atrium and left ventricle (LV), with impaired LV systolic functions (ejection fraction (EF) measured by modified Simpsons’ method was 40%), LV diastolic dysfunction impaired relaxation pattern, normal right-side chambers, and aortic root, no intra-cardiac masses or thrombi, with resting segmental wall motion abnormalities in left anterior descending artery territory.
In July 2016, he developed ischemic stroke with NIHSS 7 (minor facial paresis, grade 3 left arm, and leg weakness).
Radial pulse was 60 beats/min, bilaterally equal, regular, and well felt. Electrocardiography (ECG) (CM 300A, Comen, China) showed sinus rhythm. After fulfilling the inclusion and exclusion criteria for thrombolysis, 90 mg IV rt-PA within 40 min of arrival was administered. After injection, NIHSS became 4. Meanwhile, patient did not complain of any symptoms suggestive of peripheral vascular events.
Sixteen hours later, loss of partially regained power of the left arm with bluish discoloration, and faint radial pulsation occurred.
Urgent upper limb arterial duplex (General Electric Logic 5, USA) revealed unrecoverable ischemia with near-total occlusion of the left mid-brachial artery with total loss of flow in distal arteries, the vascular surgery team decided an above elbow amputation (Fig. 1a).
Transthoracic echocardiography (Vivid E9 machine, General Electric, Vingmed Ultrasound, Horten, Norway) done after surgery revealed 19 × 14 mm apical LV thrombus, dilated LV dimensions, with impaired LV systolic functions (ejection EF measured by modified Simpsons’ method was 35%), akinetic all apical segment, whole anterior wall and anterior septum, impaired LV diastolic function with impaired relaxation pattern with mild mitral and tricuspid valve regurgitation (Fig. 1b). Twenty-four hours Holter ECG (General Electric Health care, MARS, Milwaukee, USA) showed sinus rhythm with no detectable atrial fibrillation.