Apical Thrombus Research Articles

Rapid Formation of Left Ventricular Giant Thrombus With Takotsubo Cardiomyopathy

A 54-year-old woman diagnosed with sarcoidosis with lung involvement was admitted because of faintness associated with complete atrioventricular block. Cardiac catheterization showed normal coronary arteries and preserved left ventricular systolic function (online-only Supplemental Movie I), but endomyocardial biopsy revealed cardiac involvement. A pacemaker was implanted uneventfully, but she perceived the operation to be particularly stressful. Three hours after the operation, routine follow-up echocardiography revealed akinesis of the left ventricular apical wall, but no apical thrombi (Figure 1 …

Documentation of early improvement of left ventricular function in tako-tsubo cardiomyopathy

Reply We appreciate the comments and suggestions of Dr. Nef regarding our report. Previous reports have demonstrated that left ventricular function return to normal after 8 to 53 days after the onset of tako-tsubo cardiomyopathy [1]. Apical ballooning immediately after the onset can be evaluated with transthoracic echocardiography, to be sure, but the evaluation of its normalization is more difficult unexpectedly. Left ventriculography is more invasive, but more objective than transthoracic echocardiography to evaluate left ventricular function. I think that our report is precious because it has been first demonstrated that left ventricular function can return to normal within only 41 h with serial left ventriculogram which is an objective examination [2]. Previous studies have demonstrated various complications of tako-tsubo cardiomyopathy including congestive heart failure, cardiogenic shock, apical thrombus formation, ventricular free wall rupture, ventricular septal perforation and malignant arrhythmia [3]. I think that the earlier left ventricular function improves the less frequently at least congestive heart failure, cardiogenic shock and apical thrombus formation are likely to occur. The occurrence of arrhythmia is often associated with other factors such as QT interval prolongation or autonomic imbalance, and it may be unlikely that the time period until recovery is a suitable predictor for arrhythmia. Furthermore, tako-tsubo cardiomyopathy often occurs in patients with critical condition. In these patients, clinical outcome is dependent on the triggering disease rather than tako-tsubo cardiomyopathy, and it may be unlikely that the time period until recovery is a suitable predictor for clinical outcome. I read with great interest Dr. Nef's preliminary data between NT-proBNP and clinical outcome. We have experienced more than 60 patients with tako-tsubo cardiomyopathy, and know that the size of apical ballooning is various during early phase. I wonder if the serum level of NT-proBNP is associated with the size of apical ballooning or the time period until recovery. I am looking forward to the published report. References

Parvovirus B19–Associated Active Myocarditis With Biventricular Thrombi Results of Endomyocardial Biopsy Investigations and Cardiac Magnetic Resonance Imaging

A previously healthy 39-year-old man was admitted to our department with biventricular cardiac decompensation (New York Heart Association class IV) and acute onset of angina pectoris after a flulike disease 1 week earlier. The ECG on admission displayed ST elevations in II, III, and aVF. Troponin T on admission was increased (2.20 mg/L, normal value<0.03 mg/L), with increased creatine phosphokinase (503 U/L; normal value<171 U/L) and creatine phosphokinase myocardial band (45 U/L; normal value=10 U/L). N-terminal pro-brain natriuretic peptide was highly elevated (15,848 pg/mL; normal value<125 pg/mL). Coronary artery disease was excluded by coronary angiography. Multiple nonsustained ventricular tachycardias were recorded by Holter monitoring and telemetry. Endomyocardial biopsies obtained from the right ventricular septum demonstrated active myocarditis by histological investigations according to the Dallas criteria (Figure 1A). By immunohistological staining of endomyocardial biopsies1 and quantification using digital image analysis, highly increased focal lymphocytic (CD3+: 267.4/mm2, CD11a/LFA-1+: 498.9/mm2; Figure 1B) and macrophage infiltrates (CD11b/Mac-1+: 481.6/mm2), sarcolemmal human leukocyte antigen class I expression (area fraction of human leukocyte antigen class I=35.6%; Figure 1C), and focal abundance …

Primary cardiac plasmablastic (diffuse large B-cell) lymphoma mimicking left ventricular aneurysm with mural thrombus

Primary cardiac lymphoma is rare and is usually of the non-Hodgkin type. By definition, it involves only the heart and the pericardium, with no evidence of extracardiac disease. Primary cardiac lymphoma accounts for 1% of primary cardiac tumors and 0.5% of extranodal lymphomas [Gowda RM, Kahn RA. Clinical perspectives of primary cardiac lymphoma. Angiology 2003;54(5):599-604]. On the other hand, secondary cardiac involvement can occur in approximately 20% of patients with disseminated extracardiac lymphoma [Gowda RM, Kahn RA. Clinical perspectives of primary cardiac lymphoma. Angiology 2003;54(5):599-604]. The majority of primary cardiac lymphomas are diffuse large B-cell lymphomas with centroblastic or immunoblastic cytologic features. Herein, we describe an exceptional case of a primary cardiac plasmablastic variant of diffuse large B-cell lymphoma (Epstein-Barr virus-positive) presenting in an immunocompetent host with chest pain that mimicked a left ventricular apical thrombus.

Use of Contrast in Distinguishing Apical Mural Thrombus from Its Echocardiographic Simulators

Use of Contrast in Distinguishing Apical Mural Thrombus from Its Echocardiographic Simulators

CASE REPORT: LEFT VENTRICULAR NONCOMPACTION CARDIOMYOPATHY.

A 25-year-old man with dilated cardiomyopathy and epilepsy presented to the emergency department because of sudden onset of slurred speech and weakness of the right-sided extremities. He had been diagnosed with dilated cardiomyopathy 5 months prior to this incident, when he presented signs and symptoms of congestive heart failure and a two-dimensional echocardiogram demonstrated a dilated heart with global hypokinesia, severe mitral regurgitation, and an estimated ejection fraction of 20%. One month prior to admission, an echocardiogram demonstrated an apical thrombus, and the patient was started on warfarin. Initial examination revealed mild dysarthria, right nasolabial fold flattening, deviation of the tongue to the right side, 0/5 strength in the right upper extremity, and 2/5 strength in the right lower extremity. A grade 2/6 systolic murmur at the left lower sternal border was also appreciated. Head computed tomography revealed no evidence of acute intracranial pathology. Laboratory analyses were unremarkable, except for an INR of 1.7. The next day, all neurologic symptoms had fully resolved. A transthoracic echocardiogram with contrast media demonstrated a thin epicardium with extremely hypertrophied endocardium and prominent trabeculae with deep recesses, consistent with ventricular noncompaction cardiomyopathy. Noncompaction of the ventricular myocardium is a rare congenital cardiomyopathy resulting from arrested myocardial development during embryogenesis. During the first 8 weeks of gestation, the myocardium consists of a meshwork of interwoven fibers that form trabeculae, which allow oxygenation of tissue prior to the formation of the coronary arteries. Under normal circumstances, as the epicardial coronary vessels develop, the myocardium undergoes compaction. The process of compaction is not completed in these patients due to mutations in the gene G4.5 on the Xq28 chromosomal region. This condition is extremely rare and is often missed on conventional echocardiography.

Prompt resolution of an apical left ventricular thrombus in a patient with takotsubo cardiomyopathy

This report describes the prompt resolution of an apical left ventricular (LV)-thrombus complicating transient apical ballooning in a 74-year-old woman. The patient was admitted to our emergency department with acute chest pain and ST-elevation on the electrocardiogram. Coronary angiography showed normal coronary arteries and LV-angiography demonstrated the presence of apical ballooning akinesis associated with basal hypercontraction. Echocardiography and MRI studies confirmed the presence of LV-apex akinesis and detected an apical thrombus. Follow-up echocardiography on day 12 before discharge of the patient, revealed a marked improvement of regional contractility of the LV-apex and surprisingly the complete resolution of the LV-apical thrombus. The patient was diagnosed with takotsubo cardiomyopathy.

An unusual presentation of “tako-tsubo cardiomyopathy”

We report a case of tako-tsubo cardiomyopathy, complicated by left ventricular apical thrombus.

Incidental Diagnosis of a Left Ventricular Thrombus through Novel Magnetic Resonance Imaging Technique in a Patient Undergoing Coronary Artery Bypass Grafting

Stroke after cardiac surgery is a devastating complication. We report a case of incidental diagnosis of a left ventricular thrombus in a patient scheduled to undergo coronary artery bypass grafting. The preoperative diagnosis of an apical left ventricular thrombus was assessed by a novel, whole body MRI-angiography technique (TIMRA), which led to alteration of the operative approach as an additional thrombectomy was performed through an apical left ventriculotomy.

Switch from cyclosporine to sirolimus as a treatment of acute renal failure complicating cardiogenic shock in a heart transplant recipient

ST segment elevation acute myocardial infarction manifested by ischemic chest pain following heart transplantation is rare [1,2]. Acute renal failure complicating cardiogenic shock associated with this condition has never been previously reported. We report herein the efficacy of switching cyclosporine to sirolimus as part of the treatment of acute renal failure complicating cardiogenic shock due to ischemic chest pain acute myocardial infarction following hear transplantation. A 39-year-old man underwent orthotopic heart transplantation at our institution because of end-stage endomyocardial fibrosis. The perioperative period was uneventful. Immunosuppression consisted of cyclosporine (target blood levels: 250–350 ng/ml), mycophenolate mofetil (2 g daily) and prednisone (0.3 mg/kg daily). Four months later, he was admitted to the Critical Care Unit Hospital complaining of typical myocardial infarction-type chest pain, lasting more than 2 days. Physical examination showed no abnormality. A 12-lead electrocardiogram revealed new pathologic Q waves and ST segment elevation in the inferior and anterior leads. A Doppler echocardiogram revealed akinesis of the anterior, lateral and apical walls and thrombus in the apical region. Troponin plasma levels were 4.26 ng/ml (normal range:

A rare case of isolated left ventricular non-compaction. Importance of image technology and disease awareness for a correct diagnosis

In 1999 a 50-year-old man with sustained monomorphic ventricular tachycardia came to our institution for investigation using fundamental echocardiographic imaging. A diagnosis of hypertrophic cardiomyopathy with dilatation and apical thrombus was made. In 2003, a new echocardiographic machine equipped with second harmonic imaging modality became available and after a second investigation the diagnosis was changed to isolated left ventricular non-compaction. The echocardiogram showed hypertrabeculations involving not only the mid-septum but also the basal septum (anterior and posterior) and a thin epicardial layer without the thickened endocardial component.

Invited commentary

Dr McCarthy discloses that he has a financial relationship with AVBG, LLC. Dr McCarthy discloses that he has a financial relationship with AVBG, LLC. Back to the future? Although highly successful, aortic valve replacement still has a host of problems that need to be managed. These problems include the following: ascending aortic calcification that can embolize or complicate aortic cross clamping or aortotomy closure; a small aortic annulus that may require patch enlargement (a more complex operation with higher risks), or the possibility for patient prosthesis mismatch; possible peri-valvular leak depending on the quality of the aortic annulus and the experience of the cardiac surgeon; heart block; fibrosis and calcification from radiation heart disease; and various problems in patients with patent coronary bypass grafts such as managing proximals attached near the aortotomy, avoiding a left internal mammary artery graft that may be in the midline, and obtaining adequate myocardial protection. Oftentimes primary aortic valve replacement is a low-risk operation. However, elderly patients with comorbidities that lead to high operative risk stimulated the development of percutaneous aortic valve replacement. Just as the advent of stenting pushed surgeons to consider more creative ways to perform coronary artery bypass, the advent of percutaneous valve techniques has stimulated surgeons to consider alternative approaches to conventional aortic valve replacement. The advantages of the aortic valve bypass as described in this article are to avoid the problems of conventional aortic valve replacement in high-risk patients. A strong advantage over percutaneous aortic valve approaches is the ability to use a known commercially available prosthetic valve with a strong track record for durability. Ideal candidates for this type of approach could include patients with ascending aortic calcification, patients who require complex reoperations, and patients with a small annulus. With new strategies and new technologies this can become a very attractive alternative for a significant percentage of patients undergoing isolated aortic valve replacement (i.e., 5.8% in Gammie and colleagues’ [1Gammie J.S. Brown J.W. Brown J.M. et al.Aortic valve bypass for the high-risk patient with aortic stenosis.Ann Thorac Surg. 2006; 81: 1605-1611Abstract Full Text Full Text PDF PubMed Scopus (48) Google Scholar] experience). However, current state of the art is to modify existing conduits and valves adapted to fit this very different situation. The potential problems with the aortic valve bypass approach include pseudoaneurysm as described in their article, bleeding due to lack of control of the left ventricular (LV) apex, difficulty with the aortic anastomosis in the descending aorta due to extensive calcification of the descending aorta, kinking of the conduit because it is either too long or too short, and theoretical dislodgement of an LV apical thrombus that may not be visible by preoperative or intraoperative imaging. Should cardiopulmonary bypass be required, then it would typically employ retrograde perfusion, either from the femoral artery or a side graft from the aortic graft as described in this article, with a risk of embolization. Theoretical problems may include the nonphysiologic flow from the LV apex to the descending aorta. However, surgeons have grown used to a very successful operation that does not provide physiologic flow in coronary artery bypass. In the same way, bypassing the native aortic valve provides a clever way to work around difficult situations in some of our elderly and otherwise sick patients. With more than a 20-year history in patients, this would seem to be a strategy that has long-term durability and is not something that one would expect to see reproduced with any of the percutaneous aortic valve technologies. For this reason, surgeons should be interested in resurrecting this technique and looking forward to ways to simplify the operation and bring this to a more routine clinical care.

Anticoagulants and Transaminase Elevation

Case 1: Mr F., a 65-year-old man with hypertension and atrial fibrillation, began long-term anticoagulation with warfarin 1 year ago. He presented with a 1-week history of nausea, anorexia, jaundice, and altered mental status. His laboratory workup showed elevated serum transaminases and direct bilirubin. Could warfarin be potentially responsible? Case 2: Mr S., a 75-year-old man with diabetes and coronary artery disease, presented with an acute anterior myocardial infarction. Echocardiography showed a left ventricular aneurysm with apical akinesis and thrombus. He was started on enoxaparin, and 3 days later, he developed a rise in alanine aminotransferase (ALT) >5 times the upper limit of normal (ULN). Could this laboratory abnormality be related to enoxaparin? Drug-induced hepatotoxicity is the most common cause of acute liver failure in the United States and is the most frequently cited reason for withdrawal of an approved drug from the market.1 It occurs at rates of 1 in 1000 to 1 in 100 000 patients, making it difficult to detect in the premarketing randomized controlled trials that are required for drug approval.2 Anticoagulant-induced liver injury has been infrequently reported. Case reports have described the association of anticoagulants with asymptomatic elevation of serum transaminases, clinically significant hepatitis, and fatal liver failure.3–22 As an increasing number of patients receive long-term anticoagulation for prevention of stroke and venous thromboembolism, the rare adverse event of anticoagulant-induced liver injury is gaining attention. Ximelagatran is an oral direct thrombin inhibitor that prevents the conversion of fibrinogen to fibrin by thrombin. This agent is a prodrug and is converted to its active form, melagatran, via hepatic metabolism.23 It has a short half-life, requires twice daily administration, and produces a predictable response after oral administration. It does not require anticoagulant-level or drug-level monitoring, and it has virtually no drug-drug or drug-food …

Transesophageal Echocardiographic Bull’s Eye

A 68-YEAR-OLD woman was scheduled for surgery for diverticulosis, but her preoperative electrocardiogram prompted a stress test that was markedly positive for ischemia. Catheterization revealed occlusion of her left anterior descending and circumflex coronary arteries. Her ascending aorta was dilated (3.7 cm), there was mild aortic regurgitation, and there was a question of an apical left ventricular thrombus. Accordingly, intraoperative transesophageal echocardiographic examination was performed during surgery for coronary artery revascularization.

732 Detection of apical thrombus after anterior myocardial infarction by left ventricular opacification with contrast echocardiography

732 Detection of apical thrombus after anterior myocardial infarction by left ventricular opacification with contrast echocardiography

Atypical Presentation of Eosinophilic Endomyocardial Disease

Idiopathic hypereosinophllic syndrome is classically defined as prolonged, unexplained peripheral eosinophilia in a patient presenting with evidence of end-organ damage. The heart is frequently Involved, resulting In eosinophilic endomyocardial disease and eventually restrictive cardlomyopathy. The mortality rate is high because of progressive heart failure or ventricular arrhythmias. We describe a patient who presented with a left ventricular apical thrombus without notable peripheral eosinophilia. Findings from clinical evaluation and extensive diagnostic testing, including right ventricular biopsy, were Inconclusive. Resection of the thrombus and subjacent endomyocardium revealed eosinophilic Infiltration of the endomyocardium, which led to the diagnosis of eosinophilic endomyocardial disease. Clinicians should be aware of the variable presentation of patients with eosinophil-associated endomyocardial disease so that affected patients may benefit from early diagnosis and treatment.

Left ventricular apical thrombus after systemic thrombolysis with recombinant tissue plasminogen activator in a patient with acute ischemic stroke

BackgroundThrombolysis with recombinant tissue plasminogen activator (rtPA) is an established treatment in acute stroke. To prevent rethrombosis after rtPA therapy, secondary anticoagulation with heparin is commonly performed. However, the recommended time-point and extent of heparin treatment vary and are not well investigated.Case presentationWe report a 61-year-old man who developed an acute global aphasia and right-sided hemiparesis. Cranial CT was normal and systemic thrombolytic therapy with tPA was started 120 minutes after symptom onset. Low-dose subcutaneous heparin treatment was initiated 24 hours later. Transthoracic echocardiography (TTE) 12 hours after admission showed slightly reduced left ventricular ejection fraction (LVEF) but was otherwise normal. 48 hours later the patient suddenly deteriorated with clinical signs of dyspnea and tachycardia. TTE revelead a large left ventricular apical thrombus as well as a reduction of LVEF to 20 %. Serial further TTE investigations demonstrated a complete resolution of the thrombus and normalisation of LVEF within two days.ConclusionOur case demonstrates an intracardiac thrombus formation following rtPA treatment of acute stroke, probably caused by secondary hypercoagulability. Rethrombosis or new thrombus formation might be an underestimated complication of rtPA therapy and potentially explain cases of secondary stroke progression.

Isolated noncompaction involving the left ventricular apex in adults

We present a series of 9 adults in 2 families with isolated noncompaction of the ventricular myocardium involving the left ventricular apex. Three of these patients had been previously misdiagnosed as having dilated cardiomyopathy, apical hypertrophic cardiomyopathy, or apical mural thrombus. Phenotypic variation was observed with gradation of severity of noncompaction and left ventricular systolic dysfunction between first-degree relatives.

Resolution of Ventricular Thrombus Identified by Contrast Enhanced Cardiac MRI

A 53 year old man was referred for a contrast enhanced cardiovascular magnetic resonance (CMR) scan for assessment of anterior myocardial wall viability. An earlier coronary angiogram had shown a mid left anterior descending artery (LAD) occlusion, and echocardiography had shown mildly reduced global left ventricular function without any other abnormalities. Cine CMR images (steady state free precession sequence) showed a dilated left ventricle (LV) with reduced global systolic function [End-diastolic volume 224 mls (NR 77-195 mls); end-systolic volume 124 mis (NR 19-72 mls); ejection fraction 45%]. There was wall thinning and akinesis of the anteroapical wall and severe hypokinesis of the mid anteroseptal wall. Postgadolinium images (segmented inversion recovery turboFLASH sequence) revealed a prominent LV apical thrombus which measured 1.4 cm at greatest diameter (Figure 1). Using the late gadolinium technique there was extensive (mainly transmural) hyperenhancement (HE) involving the mid and apical septum and the apex. The patient was commenced on warfarin. A second CMR scan repeated after 4 months of warfarin therapy showed complete resolution of the thrombus in the early and late post-gadolinium images (Figures 2 and 3). CMR imaging post-contrast administration is a sensitive tool in the detection of left ventricular thrombi, and overcomes some of the near-field limitations of 2D echocardiography.

Transient cerebral ischemic attack induced by transient left ventricular apical ballooning

A 57-year-old woman had transient right hemiplegia 2 days after physical stress. An electrocardiogram exhibited T-wave inversion with QT prolongation. An echocardiogram revealed akinesia of the entire left ventricle except for the basal region. Cranial computed tomography and transthoracic echocardiography revealed an apical thrombus that disappeared 1 month later. Coronary angiography was normal. After 3 months, left ventricular wall motion had completely normalized.