we report on a 28-year - old woman , who presented two months postpartum after delivering twins with complaints of transient ischemic attack ( tia ) , dyspnea and chest pain .
physical examination demonstrated jugular venous distention ( jvd ) and s3 gallop on cardiac auscultation along with minimal rales and pedal edema .
her electrocardiogram ( ecg ) showed sinus tachycardia with lateral t wave inversion ( fig .
laboratory work up revealed an elevation in her cardiac biomarkers with a peak troponin - i level of 10.2 ng / ml . the echocardiogram showed moderate left ventricular ( lv ) dilatation with severely reduced lv systolic function and left ventricular ejection fraction ( lvef ) < 15% associated with a 2.1 cm apical thrombus ( fig .
2 ) . given the chest pain , elevated cardiac biomarkers and ecg changes suggestive of ischemia , a coronary angiography was performed which revealed two filling defects in the distal segment of the second obtuse marginal artery with a hazy appearance consistent with thrombi ( fig .
aspiration thrombectomy was performed with multiple passes at the site of thrombi and fresh clot was retrieved ( fig .
post - procedure , the patient did well ; her troponin - i levels down - trended and her symptoms improved .
she was started on oral anticoagulation for treatment for left ventricular apical thrombus and she was strongly counseled on avoidance of future pregnancies and tubal ligation . she was discharged on oral anticoagulation , and guideline directed heart failure medical therapy .
two sequential thrombi in the distal segment of the obtuse marginal 2 ( om2 ) .
repeat images demonstrating resolution of the stenosis in the obtuse marginal 2 ( om2 ) .
peripartum cardiomyopathy ( ppcm ) is characterized by the development of heart failure during the last month of pregnancy or during the first five months of the post - partum period in the absence of any other identifiable causes of heart failure ( 1 , 2 ) .
several risk factors have been identified with ppcm including ethnicity , age , pregnancy - induced hypertension or pre - eclampsia , multiparity , multiple gestations , obesity and chronic use of tocolytics ( 2 ) . in the case
described , multiple gestations , pregnancy with twins , and african descent were identified as significant clinical risk factors .
ppcm is known to increase the risk of thrombus formation and arterial emboli ( 3 , 4 ) .
the risk of acute myocardial infarction is approximately three times higher in pregnant women compared to non - pregnant women of the same age ( 5 - 6 - 7 - 8 ) . in our case ,
the inherent hypercoaguable state that exists in pregnancy along with poor lv systolic function and resulting stasis of blood flow in dilated heart , likely provided an environment for the development of an intraventricular thrombus ( 3 , 4 ) .
the findings of two intracoronary thrombi in the setting of otherwise normal coronary arteries , which were free of atherosclerotic disease , suggests embolism from lv mural thrombus as the primary mechanism of her coronary thrombi and myocardial infarction . upon review of available literature
there are only two reported cases of embolic myocardial infarction in the setting of ppcm and an associated lv thrombus ( 9 , 10 ) .
our case is unique in the aspect that catheter - based aspiration thrombectomy was performed safely for reperfusion therapy and was successful with the resolution of thrombus as documented angiographically ( fig .
, we propose that it be considered as a treatment modality in future similar cases in the absence of contraindications .
 acute coronary syndrome ( acs ) due to embolic phenomenon in the setting of peripartum cardiomyopathy ( ppcm ) and left ventricular mural thrombus is a rare occurrence . 
 there have been two known cases described in medical literature . 
 we present a unique case in which catheter - based aspiration thrombectomy was used to successfully treat a patient with acs due to coronary emboli in the setting of ppcmand left ventricular mural thrombus . 
 we believe this to be the first report of the use of aspiration thrombectomy in such a clinical case . 
Case report
Discussion