A Cardiac Thrombus: The Risk Of Anticoagulant Noncompliance In Antiphospholipid Syndrome:

Introduction Primary antiphospholipid syndrome (PAPS) is an autoimmune disorder associated with a 40–50% risk of thrombotic events and a 16% prevalence of intracardiac thrombosis. We report a treatment-refractory case of intracardiac thrombosis in a PAPS patient, the first documented in the Middle East and North Africa (MENA) region. This case highlights the critical role of cardiovascular risk stratification and management strategies in this population. Case Presentation A 47-year-old woman with a history of PAPS presented with worsening shortness of breath and chest pain over five days. Her medical history was significant for multiple episodes of pulmonary embolism (PE) and deep vein thrombosis (DVT). She had discontinued anticoagulation therapy three years earlier *due to socioeconomic challenges during the COVID-19 pandemic. Investigations revealed a chest X-ray demonstrating left upper zone ground-glass opacification and right middle zone collapse, consistent with multiple PEs. Cardiac magnetic resonance imaging (MRI) (Figures 1–4) identified *non-enhancing filling defects in the right atrium, protruding through the tricuspid valve during diastole, accompanied by right ventricular dilation and hypokinesia. Her ejection fraction was 55%, with no evidence of pericardial effusion. The patient was non-responsive to medical therapy and was referred for surgical thrombectomy. Conclusion While thrombotic complications in PAPS are well-documented, surveillance primarily targets PE, DVT, and obstetric morbidity, often overlooking intracardiac thrombi. This case underscores the need for heightened clinical suspicion and routine cardiovascular assessment in PAPS patients, particularly those with a history of anticoagulation nonadherence. Incorporating cardiac imaging into thrombotic risk evaluation may facilitate early detection and improve outcomes in this high-risk population.