Ann Thorac Surg 2000;70:658-660
© 2000 The Society of Thoracic Surgeons
Case report
Ventricular thrombosis and systemic embolism in bodybuilders: etiology and management
Kathryn McCarthy, MB, BSa,
Augustine T.M. Tang, FRCSa,
Malcolm J.R. Dalrymple-Hay, FRCSa,
Marcus P. Haw, FRCSa
a Department of Cardiac Surgery, Wessex Cardiac & Thoracic Unit, Southampton General Hospital, Southampton, United Kingdom
Address reprint requests to Dr Tang, Department of Cardiac Surgery, Wessex Cardiac & Thoracic Unit, Southampton General Hospital, Tremona Rd, Southampton SO16 6YD, United Kingdom
e-mail: gustmtang{at}aol.com
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Abstract
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Increased thrombogenicity and acute embolism are well-recognized complications of chronic anabolic steroid abuse. The following cases highlight such dangers in steroid-enhanced bodybuilders who developed intracardiac thrombosis that subsequently embolized. Systemic anticoagulation and surgical thrombectomy constituted the mainstay treatment. This represents the first report of such devastating cardiovascular complications after anabolic steroid abuse and their management.
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Introduction
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Adverse systemic effects of anabolic steroid abuse including arterial thrombosis are well documented. However, thrombosis in the left ventricle and the propensity for systemic embolism have hitherto not been recognized. We describe our experience of this complication in two young bodybuilders who followed different management strategies.
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Case reports
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Patient 1
A 35-year-old competitive bodybuilder presented with a 3 day history of central chest pain, back pain, and breathlessness following a 4 to 6 week flulike illness. He was an exsmoker with a family history of coronary artery disease and had been "cycling" various testosterone analogs including nandrolone and nandralone for many years. Cycling involves 2 to 3 months of continuous administration of the drug punctuated by abstinence of 2 to 3 weeks. Electrocardiography confirmed sinus rhythm. Myocarditis was initially diagnosed for which angiotensin-converting enzyme inhibitors and diuretics were instituted. The patient was allowed to continue with anabolic steroid treatment to avoid withdrawal problems. However, despite treatment he developed pulmonary edema and transthoracic echocardiography demonstrated dilated cardiomyopathy with severe global left ventricular dysfunction. Steroid-induced cardiomyopathy was suspected, which led to the immediate cessation of the drug. Echocardiograhy repeated 5 days later demonstrated a large pedunculated thrombus in the left ventricle. After systemic anticoagulation the thrombus disappeared between the seventh and eighth day of treatment and echocardiography showed return of normal left ventricular function. However, 4 days later he complained of sudden pain in both feet. Clinical assessment suggested acute embolic occlusion of the tibial arteries, most probably from the ventricular thrombus, although critical ischemia was absent in either leg. The symptoms completely resolved with expectant treatment and continued systemic anticoagulation before discharge. At 6 months’ follow-up the patient staged a full recovery.
Patient 2
A 31-year-old casual bodybuilder presented with bilateral acute ischemic legs after harboring a 6-month history of recurrent leg pain initially managed by his family physician as tendinitis. Clinical assessment revealed no limb pulses distal to the right groin and the left popliteal fossa. The patient was a nonsmoker with no family history of arteriosclerosis and had been cycling various anabolic steroids—testovarin, sustanon, and dianabol—for 8 years. The only abnormal blood test was an increased C-reactive protein level of 53.1. Angiography showed normal aortic arch, ascending and thoracic aorta, but total occlusion of the right superficial femoral artery (Fig 1) with no distal filling and occluded left popliteal artery with collateral distal filling. Transthoracic echocardiography revealed the embolic source to be a large pedunculated thrombus in the left ventricle and mild global ventricular dysfunction (Fig 2). Urgent operation was undertaken to prevent further embolization and revascularize the limb. After median sternotomy and institution of cardiopulmonary bypass, an aortotomy was made under cardioplegic arrest to allow the ventricular thrombus (2 by 3 cm) to be retrieved across the aortic valve. After saline lavage of the ventricle, intraoperative transesophageal echocardiography demonstrated no residual thrombus. This was confirmed by transthoracic echocardiography on the following day. Right femoral embolectomy was performed under the same anesthetic. The patient made an uneventful postoperative recovery with satisfactory limb perfusion, normal left ventricular function, and adequate systemic anticoagulation before discharge.
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Fig 1. Peripheral arterial angiogram showing an abrupt halt to the progression of contrast in the right superficial femoral artery (indicated by arrow).
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Fig 2. Transthoracic echocardiography demonstrating a large spherical thrombus within the left ventricle (indicated by arrow).
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Comment
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Anabolic steroid abuse is an increasing problem, particularly among athletes and bodybuilders striving for excellence. Ready access through local outlets and the Internet undoubtedly contributed to the recent surge in steroid usage. However, little or no warning of potentially fatal adverse effects is usually given.
Cycling involves administering one or more steroids, typically in doses 10 to 100 times greater than those used therapeutically for more than 6 to 12 weeks with intervals of steroid-free "holidays." This regime is believed to maximize end-organ effects, prevent gradual loss of benefits with chronic usage, and avoid detection on drug testing. When received in large doses, often by bodybuilders, the pituitary–testicular axis frequently becomes suppressed resulting in testicular atrophy and azoospermia [1]. Other common problems include gynecomastia, hot flushes, and fluid retention [1]. Premature closure of epiphyseal plates has also been reported in teenage anabolic steroid users resulting in stunted growth. Serious cardiovascular complications reported include systemic arterial thrombosis leading to acute ischemic legs [2], brain injury [3], myocardial infarction, ventricular arrhythmia, and congestive heart failure [4]. The incidence of intracardiac thrombosis was once recognized in association with anabolic steroid usage, although after nonintervention, the patient was lost to follow-up [4]. The pedunculated nature of these thrombi, as opposed to platelike mural thrombus commonly encountered, may partly explain their propensity for embolization. These patients represent reports of successful intervention for ventricular thrombosis and systemic embolization associated with chronic abuse of anabolic steroid.
In summary, having adopted a conservative approach in the first patient, he was fortunate to escape neurologic sequelae. We would now recommend early surgical intervention to avoid potentially lethal thromboembolic complications.
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References
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Marshall E. The drug of champions. Science 1988;242:183-184.[Free Full Text]
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Falkenberg M., Karlsson J., Ortenwall P. Peripheral arterial thrombosis in two young men using anabolic steroids. Eur J Endovasc Surg 1997;13:223-226.
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Laroche G.P. Steroid anabolic drugs and arterial complications in an athlete. Angiology 1990;41:964-969.
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Nieminen M.S., Ramo M., Vitasalo M., et al. Serious cardiovascular side effects of large doses of anabolic steroids in weight lifters. Eur Heart J 1996;17:1576-1583.[Abstract/Free Full Text]
Accepted for publication December 14, 1999.
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Abstract
Introduction
