Apical Thrombus Research Articles

The Utility of 320 Row Multi-Detector Computed Tomography in Evaluating Patients with Left Ventricular Assist Devices

Purpose The number of patients undergoing implantation of a left ventricular assist device (LVAD) as either a bridge to transplant, or increasingly as destination therapy is increasing. Evaluation of these patients with standard diagnostic tests such as echocardiography, catheterization, or nongated computed tomography is very difficult due to imaging challenges. We present the use of 320 row MDCT for the imaging evaluation of LVAD patients. Methods and Materials Between March and November 2012, 17 patients were referred for MDCT evaluation. CT parameters were: Collimation- 320 X 0.5mm, Voltage- 120kV, Tube Current- 300-500 mA. The average radiation dose was 10 mSv. Results All 16 patients undergoing MDCT evaluation had good quality studies. The LV and LA were able to be evaluated for thrombus. The inflow cannula and its position were able to be seen as well as the outflow graft to the aorta. [ figure 1 ] The driveline was also able to be seen and evaluated. [ figure 2 ] One patient was found to have LV apical thrombus. One patient had significant LV remodeling that significantly changed her cannula position in the LV. No other abnormalities were discovered. Conclusions The number of patients with LVADs is increasing. Current imaging methods are inadequate for evaluation and troubleshooting of these device. 320 row MDCT may be useful as an imaging modality for LVAD evaluation.

Cardio-embolic stroke following remote blunt chest trauma

A cardio-embolic stroke as a sequela of remote blunt chest trauma is a rare clinical presentation. Blunt chest trauma can cause various acute cardiac complications like arrhythmias, cardiac contusion etc. However, delayed consequences such as left ventricular thrombus resulting in thromboembolic phenomena are reported infrequently.A 30-year-old healthy man presented to an outside facility with transient neurological deficits. An MRI brain showed lesions suggestive of embolic etiology. A trans-thoracic echocardiogram (TTE) showed a 1.5 × 1.5 cm mass present in the left ventricular (LV) apex. Patient was transferred to our institution for cardiac surgery evaluation. On detailed questioning, he reported an incident of blunt chest trauma during a martial arts exhibition fight that took place 2 years back. Given this history, a cardiac catheterization was done, which showed 30% stenosis in mid-left anterior descending artery (LAD) without any other significant obstructive lesion. A trans-esophageal echocardiogram (TEE) showed akinesis of the LV apex and confirmed TTE finding of a mass, consistent with an apical thrombus. Surgery was deferred and patient was started on anticoagulation. A cardiac MRI done 2 weeks later showed evidence of apical infarction in the LAD territory.LAD is the most commonly affected coronary vessel by blunt traumatic injuries, likely due to its vulnerable anatomical position on the anterior aspect of the heart. A variety of mechanisms including intimal tear, rupture and spasm have been implicated in the pathogenesis of myocardial infarction after blunt chest trauma.

A Case of Persistent Apical Ballooning Complicated by Apical Thrombus in Takotsubo Cardiomyopathy of Systemic Lupus Erythematosus Patient

Takotsubo cardiomyopathy, which is also known as "transient apical ballooning", is a cardiac syndrome associated with emotional and physical stress that occurs in postmenopausal women. It may mimic acute coronary syndrome but coronary angiography reveals normal epicardial coronary arteries. The prognosis is favorable with the normalization of wall motion abnormalities within weeks. We report a case of persistent apical ballooning complicated by an apical thrombus in Takotsubo cardiomyopathy of systemic lupus erythematous patient. Takotsubo cardiomyopathy may not be always transient and left ventricular thrombus can occur in the disease course as our patient.

Takotsubo Cardiomyopathy and 5-Fluorouracil: Getting to the Heart of the Matter

Takotsubo cardiomyopathy is a rare but increasingly recognized phenomenon, which can occur as a side-effect of chemotherapeutic agents, in particular, the antimetabolite 5-fluorouracil. We describe a case of delayed Takotsubo cardiomyopathy after 3 weeks of adjuvant 5-fluorouracil for resected rectal adenocarcinoma in a 66-year-old female, supported by angiographic, electrocardiographic, and echocardiographic features. As a complication, she developed an apical mural thrombus with subsequent cerebral thromboembolic events and was successfully anticoagulated to make a full recovery. We present a review of the literature on Takotsubo cardiomyopathy secondary to 5-fluorouracil and the rare occurrence of thromboembolic complications. As this is a significant clinical phenomenon which involves a multispeciality approach to management, oncologists and cardiologists need to recognize it as a potential toxicity of a widely administered chemotherapeutic drug.

Concomitant diagnosis of a large apical right ventricular thrombus in a newly diagnosed case of arrhythmogenic right ventricular dysplasia

Concomitant diagnosis of a large apical right ventricular thrombus in a newly diagnosed case of arrhythmogenic right ventricular dysplasia

Unconventional etiology for heart failure and stroke: Non-compaction cardiomyopathy

Introduction: Non­compaction cardiomyopathy is a rare, primary, genetic cardiomyopathy that results from intra­uterine arrest of the compaction process. It commonly involves the apical area of the left ventricle, and uncommonly involves the right ventricle. Case Report: A 45­year­old male presented to the hospital for heart failure. He was started on anticoagulation for the apical thrombus and later he suffered cerebrovascular accident. On careful evaluation he was found to have ventricular non­compaction both in right and left ventricles. Conclusion: Non­compaction cardiomyopathy should be considered in all refractory cases of heart failure. Anticoagulation is crucial in patients with decreased systolic function and atrial fibrillation.

左室内血栓を有し, たこつぼ様壁運動の遷延を認め, 難治性心室頻拍が生じた1例

左室内血栓を有し, たこつぼ様壁運動の遷延を認め, 難治性心室頻拍が生じた1例

Occurrence of Simultaneous Left Ventricular Mural Thrombus and a Fresh Floating Thrombus in the Left Common Carotid Artery

Stroke is the third-leading cause of death in the United States after cardiovascular disease and cancer. It remains the leading cause of serious long-term disability in the United States. Mechanisms of ischemic stroke include embolism, decreased perfusion, and thrombosis. Cardio-embolism, defined as a source of embolus originating from the heart, may account for an estimated 20% of ischemic strokes. Intracavity thrombus from wall motion abnormalities, especially in the first 2 weeks after anterior myocardial infarction, has been described as a potential cardiac source of emboli. The finding of an LV apical thrombus detected by transthoracic echocardiography as a possible embolic source and the simultaneous discovery of a fresh floating thrombus in the left common carotid artery as detected by duplex ultrasonography are rare findings. We report a case of a 77-year-old man with both of these findings with signs and symptoms of a myocardial infarction with late presentation. Trans-thoracic echocardiography revealed an echo density consistent with mural thrombus that was located adjacent to the severely hypokinetic left ventricular apical wall. A carotid duplex revealed a totally occluded left common carotid artery with an echo density suggestive of thrombus. Atheromatous deposits in the extra-cranial carotid arteries may cause localized thrombosis. However, a free-floating thrombus in the carotid artery could be a result of a cardiac source of embolism. Cardioembolic syndromes typically presents as emergencies. Prompt diagnosis and urgent optimal medical and surgical treatments are warranted because these patients have an increased risk for distal embolization and vessel occlusion that lead to severe disability or death.

Neu aufgetretener linksventrikulärer Thrombus im Verlauf einer Tako-Tsubo-Kardiomyopathie

A 70-year-old woman complained of persistent angina pectoris and exertional dyspnoea after a fierce row with a dog owner. Five days after the conflict she visited our clinic. The ECG showed T-wave inversions across the inferior and anterior leads as well as a prolonged QTc interval (490 ms). NTproBNP was elevated (6733 ng/l) while troponin T was normal. Echocardiography and ventriculography during cardiac catheterisation demonstrated an impaired left ventricular function (EF 55 %) with apical akinesia. Coronary artery disease was ruled out by coronary angiography. Based on these findings stress-related cardiomyopathy (Tako-tsubo syndrome) was diagnosed. Guideline-based therapy of heart failure was performed. At control examination 13 days after the initial event left ventricular function had improved but now a new left ventricular apical thrombus was detected. Therefore, oral anticoagulation therapy was started. In cases of tako-tsubo cardiomyopathy with apical akinesia it should be noted that a left ventricular thrombus can develope within few days.

Vascular purpura revealing a severe dilated cardiomyopathy with left ventricular apical thrombus

We present a case of vascular purpura revealing an intra-cardiac left-sided thrombus complicating an end-stage dilated cardiomyopathy. Vascular purpura main etiologies encompass the wide specturm of vasculitides and microvascular-occlusion syndromes. Among them, cardiac embolism represents an unusal but potentially severe etology.

Cardiac thrombus and conduction disorder in takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a reversible form of left ventricular dysfunction with an apparently benign natural history after left ventricular recovery. Rarely there are complications such as arrhythmias and apical thrombus. We describe a case of takotsubo cardiomyopathy complicated with apical thrombus and persistent complete atrioventricular block after improvement of left ventricular wall motion.

Cardiac thrombus and conduction disorder in takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a reversible form of left ventricular dysfunction with an apparently benign natural history after left ventricular recovery. Rarely there are complications such as arrhythmias and apical thrombus. We describe a case of takotsubo cardiomyopathy complicated with apical thrombus and persistent complete atrioventricular block after improvement of left ventricular wall motion.

Late Potentials Abolition as an Additional Technique for Reduction of Arrhythmia Recurrence in Scar Related Ventricular Tachycardia Ablation

To evaluate the efficacy of radiofrequency ventricular tachycardia (VT) ablation targeting complete late potential (LP) activity. Sixty-four consecutive patients (pts) with recurrent VTs and coronary artery disease or idiopathic dilated cardiomyopathy were evaluated. Fifty patients (47 male; 66.2 ± 10.1 years) had LPs at electroanatomical mapping; 35 patients had at least 1 VT inducible at basal programmed stimulation. After substrate mapping, radiofrequency ablation was performed with the endpoint of all LPs abolition. LPs could not be abolished in 5 patients despite extensive ablation, in 1 patient because of localization near an apical thrombus, and in 2 patients because of possible phrenic nerve injury. At the end of procedure, prevention of VT inducibility was achieved in 25 of 35 patients (71.4%) with previously inducible VT; VT was still inducible in 5 of 8 patients with incomplete LP abolition; and in 5 of 42 patients (16.1%) with complete LP abolition (P < 0.01). After a follow-up of 13.4 ± 4.0 months, 10 patients (20.0%) had VT recurrences and one of them died after surgical VT ablation; VT recurrence was 9.5% in patients with LPs abolition (4/42 pts) and 75.0% (6/8 pts) in those with incomplete abolition [positive predictive value (PPV): 75%, negative predictive value (NPV): 90.4%, sensibility: 60.0%, and specificity: 95.0%, P < 0.0001); although it was 12.5% (5/40 pts) in patients without inducibility VT after the ablation, and 50% (5/10 pts) in those with inducible VT (PPV: 50%, NPV: 87.5%, sensitivity: 50.0%, and specificity: 87.5%, P = 0.008). LP abolition is an effective endpoint of VT ablation and its prognostic value compares favorably to that achieved by programmed electrical stimulation.

Loeffler myocarditis in pre‐B acute lymphoblastic leukaemia with t(5;14)(q31;q32)

A 17-year-old male with a previous history of T-cell nonHodgkin lymphoma was noted on follow-up to have a white cell count of 79·1 9 10/l and an eosinophil count of 8·8 9 10/l. Peripheral blood film shown (top left). Immunophenotyping confirmed precursor B-cell acute lymphoblastic leukaemia (ALL). Cytogenetic analysis demonstrated t(5;14)(q31;q32), t(7;12)(p15;q13), trisomy 19 and monosomy 20 (top right). Fluorescent in situ hybridization for FIP1L1-PDGFRA was negative. During induction chemotherapy (dexamethasone, daunorubicin, vincristine and asparaginase), he developed chest pain. Cardiac magnetic resonance imaging (CMR) was performed (bottom). This showed a small pericardial effusion, normal biventricular size and function, a small left ventricular apical thrombus, myocardial oedema and extensive subendocardial late enhancement, classical for eosinophilic infiltration. A thrombophilia screen demonstrated heterozygosity for F2 G20210A. Despite anticoagulation with low molecular weight heparin (LMWH), he developed lower limb deep vein thromboses, pulmonary emboli and a left cephalic vein thrombosis. He subsequently died of progressive disease after a myeloablative allograft. Eosinophilic ALL with t(5;14)(q31;q32) is rare. Loeffler myocarditis, diagnosed on CMR, showed three typical features of myocardial involvement (oedema, thrombus and late enhancement). We suggest this noninvasive procedure as an alternative to tissue diagnosis of Loeffler endocarditis. Extensive thromboembolism has been reported in B-ALL with t(5;14) translocation and we therefore suggest consideration of thromboprophylaxis with LMWH.

Surgical treatment of giant left ventricular apical thrombus diagnosed with contrast echocardiography in patient with previous anterior myocardial infarction

Abstract Introduction We report a case of a 66-year-old man with previous anterior ST-elevated myocardial infarction, treated with primary percutaneous coronary intervention and insertion of drug eluting stent on the left anterior descending coronary artery, and left ventricular (LV) apical aneurysm due to no-reflow. After 2 months follow-up contrast echocardiography allowed to detect giant apical LV thrombosis and to exclude impending LV wall rupture. Anticoagulant oral therapy failed to dissolve the thrombus. Aneurismectomy with left ventricular remodeling and excision of the thrombus was performed successfully and the patient was discharged in good condition. Conclusions Contrast echocardiography was fundamental in diagnosis of LV thrombus excluding an impending LV wall rupture and to guide treatment.

Abnormal Left Ventricular Vortex Flow Patterns in Association With Left Ventricular Apical Thrombus Formation in Patients With Anterior Myocardial Infarction

The current study was designed to investigate the correlation between the left ventricular (LV) vortex flow pattern and LV apical thrombus formation in patients with acute anterior wall myocardial infarction (MI). Fifty-seven patients with acute anterior wall MI were enrolled in this study. Eighteen patients with apical thrombus (thrombus group) and 39 patients without apical thrombus (non-thrombus group) underwent 2-dimensional contrast echocardiography (CE). Morphology and pulsatility parameters of the LV vortex were measured using Omega flow(®) and compared between the 2 groups. In the thrombus group, the vortex was located more centrally and did not extend to the apex. In the thrombus group, quantitative vortex parameters of vortex depth (0.409±0.101 vs. 0.505±0.092, respectively; P=0.002) and relative strength (1.574±0.310 vs. 1.808±0.376, respectively, P=0.034) were significantly lower than the non-thrombus group. Following multivariate analysis, the vortex depth below 0.45 remained a significant independent parameter for formation of the LV apical thrombus (odds ratio 9.714, 95% confidence interval 1.674-56.381, P=0.011). These findings suggest that the location and pulsatility power of the LV vortex are strongly associated with the LV thrombus formation in patients with anterior MI. Therefore, LV vortex flow analysis using CE can be clinically useful for characterizing and quantifying the risk of LV apical thrombus in patients with anterior MI.

004 Contrast induced nephropathy after primary PCI for STEMI: Usefulness of a new definition

including age, sex and time delays to admission. Interestingly, dyslipidemia and history of MI was less frequent in PE group. Plasma CRP levels on admission were markedly higher in PE patients. Prior chronic treatments were less frequent in PE group, in particular for aspirin (11 vs 19%, p=0.027), ACE inhibitor (10 vs 18%, p=0.014) and statin (15 vs 23%, p=0.054). Acute treatments were similar, except for BetaBlocker that were more used in patients without PE. Patients with PE were more likely to suffer from STEMI and altered LVEF. Hospital complications such as death, or heart failure (12 vs 7%, p=0.016, 47 vs 28%, p=0.001), and mechanical complications including atrial fibrillation, wall rupture, apical thrombus and mitral regurgitation (respectively, 20 vs 9%, p<0.001, 7 vs 0.5%, p<0.01, 8 vs 0.7%, p<0.01, and 8 vs 3%, p=0.03) were more frequent in PE group.

Left ventricular apical and atrial appendage thrombus with hypertrophic cardiomyopathy in sinus rhythm: a case report.

A 47-year-old female with a history of untreated hypertension and diabetes mellitus was referred because of a left ventricular echocardiographic mass with congestive heart failure. At the time of admission, she had already had a cardio-embolic stroke with loss of recent memory and slight paralysis of the right upper arm. It was difficult to distinguish between thrombus and tumor. However, her clinical condition required surgical resection as soon as possible. We performed cardiac CT to evaluate the coronary arteries and to scan the mass at the left ventricular apex. This CT evaluation revealed another mass at the left atrial appendage. Thus, these two masses were highly suggestive of thrombi. Subemergency surgical resection of the two masses and a part of the myocardium at the left ventricular apex was successfully performed. The pathological results showed that both the mass in the left ventricular apex and the mass in the left atrial appendage were thrombi, and the myocardial disarray confirmed the echocardiographic diagnosis as hypertrophic cardiomyopathy.

Interventionalists beware: the apical thrombus!

Recent myocardial infarction is a recognized risk factor for ischemic stroke. Patients who have a stroke in the peri-infarct period are usually in hospital and therefore well placed to access early cerebral reperfusion therapy. However, due to the risk of myocardial rupture, recent myocardial infarction is considered a contraindication to intravenous thrombolysis, which is usually the first-line therapy for the treatment of ischemic stroke. We report a case in which intravenous thrombolysis was safely and effectively used to treat acute ischemic stroke in a patient who had suffered an acute myocardial infarct within the previous 48 h. We also highlight the lack of evidence-based guidelines for the treatment of stroke in this important subgroup of patients.

Acute myocardial infarction in young adults with Antiphospholipid syndrome: report of two cases and literature review

Acute myocardial infarction (AMI) is rarely associated with antiphospholipid syndrome. The treatment of these patients is a clinical challenge. We report the observations of 2 young adults (1 woman and 1 man), admitted in our acute care unit for acute myocardial infarction (AMI). A coagulopathy work-up concludes the existence of antiphospholipid syndrome (APS) in the 2 cases. APS syndrome was considered primary in 2 cases. All patients presented an intense inflammatory syndrome (high level of CRP). Anticardiolipine was present in the 2 cases. However, anti B2 glycoprotein I antibodies were detected in only one case. Emergency percutaneous transluminal coronary angioplasty (PTCA) with direct stenting had been performed successfully only in the first case, and the follow-up was uncomplicated. Thereafter, long-term oral anticoagulant appeared to be effective. The last patient was admitted because of peripheral acute ischemia of legs. Standard electrocardiogram showed signs of previous silent anteroseptal wall myocardial infarction confirmed by echocardiography. The latter revealed an apical thrombus and a very low left ventricular ejection fraction. Amputation of the right leg was necessary because of consultation occurred too late. However, he died four weeks later. Primary antiphospholipid syndrome should be considered as a cause of acute myocardial infarction in young adults, and PTCA with anticoagulant treatment is effective for initial treatment of this complication.