Abstract
Thrombi represent the most frequently found intracardiac masses. Left ventricular thrombus (LVT) is an important complication in patients with ischemic heart diseases and in those with dilated cardiomyopathy and systolic heart failure. The diagnosis of left ventricular thrombus remains important since anticoagulation will reduce the risk of systemic embolization and stroke. Despite advances in other imaging modalities, echocardiography remains the most important tool for diagnosis and risk stratification in patients predisposed to develop left ventricular thrombi. Mural thrombi formed on the left ventricular endocardium and horseshoe-shaped in chronic dilated cardiomyopathy, masquerading as left ventricular endomyocardial fibrosis was diagnosed by transthoracic 2D echocardiographic imaging in a 38 years old middle aged man. Background of this case highlighted the pathophysiology, high risk echocardiographic features and the role of anticoagulant therapy in LV thrombus with dilated cardiomyopathy.
Highlights
Thrombus is defined as a discrete echo dense mass with defined margin, distinct from the endocardium and seen throughout systole and diastole
In patients with dilated cardiomyopathy, low-velocity swirling of blood within the left ventricle predisposes to the development of a thrombus due to altered hemodynamics associated with poor myocardial contractility
Transthoracic 2D echocardiography revealed dilated cardiomyopathy with a measured ejection fraction of 23% and a chronic, laminar, flat, fibrosed, organized, large horseshoe-shaped thrombus occupying the apex and adjacent portion of LV cavity as shown in Figure 1, Figure 2 and Figure 3
Summary
Thrombus is defined as a discrete echo dense mass with defined margin, distinct from the endocardium and seen throughout systole and diastole. The pathophysiologic mechanism for left ventricular thrombus (LVT) formation in the so-called “Virchow’s triad” was postulated in patients with acute myocardial infarction or in those with dilated cardiomyopathy and congestive heart failure. The triad consists of stasis of blood, endothelial injury or dysfunction and a hypercoagulable state. The combination of blood stasis, endothelial injury and hypercoagulability, often referred to as Virchow’s triad, is a prerequisite for in vivo thrombus, composed of fibrin, red blood cells, and platelets. Abnormal myocardial contraction or endocardial injury promotes cardiac mural thrombi formation. In patients with dilated cardiomyopathy, low-velocity swirling of blood within the left ventricle predisposes to the development of a thrombus due to altered hemodynamics associated with poor myocardial contractility. A chronic fibrosed organized thrombi visible as horseshoe-shaped in LV cavity around the apex in chronic dilated cardiomyopathy is uncommon and so this case had been reported
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