Introduction: The incidence of left ventricular thrombus (LVT) in patients with stress induced cardiomyopathy is 5 to 8%. In a systematic review, the incidence was noted to be 5% with one third of patients developing a resultant embolic phenomenon. Here we discuss an elderly gentleman who presented with acute limb ischemia secondary to infrarenal aortic obstruction secondary to embolic phenomenon, originating from LVT related to stress induced cardiomyopathy. 

Case Report: A 65-year-old male with past medical history of seizure disorder and peripheral artery disease status post remote right common/external iliac stenting presented with acute onset left flank pain for 2 days. He was involved in a motor vehicle accident (MVA) 3 weeks prior to his presentation, requiring spinal instrumentation. 

On arrival, patient was afebrile and hemodynamically stable. Examination was remarkable for absent bilateral femoral and pedal pulses with associated pallor and poikilothermia. Sensory/motor sensation was intact bilaterally. Ankle-brachial index 0.0 on right and 0.39 on left. Abdominal exam was benign. ECG showed normal sinus rhythm with right bundle branch block and associated ST-segment abnormalities. Peak troponin-I was 0.562 ng/mL. Urgent computed tomographic angiography revealed acute segmental left renal infarct with acute infra-renal aortic occlusion besides an incidental finding of radiopaque density within left ventricular cavity on partial chest slices suspicious for presence of a LVT. Patient was started on IV heparin. 

Transthoracic echocardiogram showed severe left ventricular dysfunction estimated at 30 to 35% with regional wall motion abnormalities consistent with left anterior descending arterial territory infarct/ischemia versus stress induced cardiomyopathy with and a moderate sized apical thrombus. Coronary angiography showed minor irregularities of the epicardial vessels without obstructive disease. Clinical presentation was deemed to be secondary to stress-induced cardiomyopathy occurring during patient’s recent MVA which likely led to development of LVT. 

Patient subsequently underwent right axillary bifemoral bypass with resolution of acute limb ischemia. The segmental left renal infarct was managed conservatively. Renal function remained stable throughout. 

Secondary to patient’s lack of reliable follow-up for warfarin therapy, he was transitioned from heparin to off-label apixaban for management of LVT besides aspirin and other guideline-directed medical therapy for peripheral arterial disease and stress-induced cardiomyopathy 

Conclusion: With our case, we intend to discuss LVT thrombus with resultant embolic infarction as an infrequent complication of stress induced cardiomyopathy. Timely identification and appropriate intervention are crucial in reducing mortality in such patients, and our patient serves to highlight the same.