Presentation and diagnosis A 62-years old male was brought to the emergency department after being found unconscious, lying on his left side. He was last seen 1 week before. Past medical history revealed ischemic cardiomyopathy with reduced ejection fraction of 35% after ST-segment elevation myocardial infarction 3 months before, subject to coronary angioplasty of 2 vessels (left anterior descending artery with drug-eluting stent and circumflex artery with balloon angioplasty). He had poor therapeutic compliance with missing cardiology appointments. On examination, he was hypothermic and hemodynamically unstable with signs of hypoperfusion. He was admitted for septic shock with origin in a decubitus ulcer on his left-hand dorsum. Head CT-scan revealed sub-acute ischemic stroke in the right middle cerebral artery territory. He started fluid therapy, vasopressors and large spectrum antibiotics with favorable clinical evolution and no heart failure symptoms but remained febrile. Meanwhile, Proteus hauseri had grown in blood cultures. An echocardiography was performed excluding infectious endocarditis and revealing a large apical thrombus on the left ventricle. Management Therapeutic anticoagulation with enoxaparin was initiated and antibiotic was de-escalated according to the antibiogram. Later on, anticoagulation was switched to warfarin (target INR∼2.0–3.0). When clinically stable, was discharged home with anticoagulation and clopidogrel, with an echocardiography scheduled after 3 months. Learning points Left ventricular thrombus is a rare complication of ischemic cardiomyopathy with high risk of adverse outcomes, including ischemic stroke and death. Vitamin K antagonists are usually preferred to direct oral anticoagulants in the management of these patients, but further research is needed.