Assessment Of Left Ventricular Thrombus Research Articles

Assessment of Left Ventricular Thrombus Using Cardiac Computed Tomography

Left ventricular thrombus (LVT) can be missed on transthoracic echocardiogram and although cardiac magnetic resonance imaging (cMRI) is the gold standard of assessment, access to cMRI is limited. Cardiac computed tomography (CCT) has been suggested as an alternative. This study prospectively investigated the optimal CT acquisition time to assess for the presence of LVT. Patients admitted to Auckland City Hospital, New Zealand, found to have LVT and no contraindication to CCT were recruited. The CCTs were performed timed at peak contrast enhancement arterial-phase (CTA), 60–70 seconds delay venous-phase (CTV), and delay multi-energy CT (CTD). The study was supported by the Greenlane Cardiovascular Fund. Eleven patients were recruited over a 30-month period. The mean age was 50±13 years and 73% were male. An LVT was confirmed on CCT in 10 patients (91%). One patient with LVT on TTE did not have LVT on CCT and cMRI. Transthoracic echocardiography (TTE) failed to detect 18% of LVT. Amongst the three CT protocols, LVT was best detected on CTV when the thrombus and adjacent myocardium demonstrated good tissue differentiation, allowing for improved thrombus detection. Although CTD was able to detect the presence of an LVT, there was a reduction in image quality. Resolution of LVT was seen in 78% of patients at 3 months and all LVT had resolved by 6 months. The mean radiation dose for CTA was 2.6±2.4 mSv, 1.5±0.9 mSv for CTV, and 3.6±1.8 mSv for CTD. There was improved tissue separation between the adjacent myocardium and LVT and thereby improved LVT detection using venous-phase CT (CTV).

Transthoracic Echocardiogram Can Accurately Assess Left Ventricular Thrombus in Patients Who Receive an LVAD: Comparison with Intraoperative Intraventricular Visualization

Purpose Severe left ventricular (LV) dysfunction often presents with left ventricular thrombi (LVT). Data on patients with LVT who receive a left ventricular assist device (LVAD) are scarce. We aimed to analyze the comparative diagnostic value of a pre-implant transthoracic echocardiogram (TTE) for LVT detection against the intraoperative findings at LVAD implantation. Methods We reviewed patient characteristics, TTE images, trans-esophageal echocardiographic images, intraoperative findings and pathology reports from the Center for Advanced Heart Failure Data Registry from May 2012 to August 2018. 299 patients received their first LVAD in this period, 238 of them had an LVAD implanted with the use of cardiopulmonary bypass (CPB), and 61 underwent operations without the use of CPB. In all patients who had CPB during their operation, the left ventricle was intraoperatively visually explored. We analyzed the results of 233 patients who had complete data sets. Results Preoperative TTE identified LVT in 23 of the 233 patients (9.9%); 15 patients (6.4 %) had LVT confirmed via intraventricular visualization. Most of the LVTs were located in the LV apex. Of the 15 patients with visual LVT confirmation, the preoperative TTEs identified an LVT on all but one case. Thus, preoperative TTEs of LVT had a high sensitivity (93%) and specificity (96%), as well as high positive (61%) and negative predictive values (99.5%). In patients with preoperatively identified LVT, all thrombi were removed during LVAD implantation. As compared to those without, patients with LVT were younger (44 ± 17 vs. 56 ± 13 y, p=0.007) and had a lower prevalence of arterial hypertension (50% vs 92%, p Conclusion This is the largest and most complete study to assess TTE accuracy compared with intraoperative findings in LVAD patients. TTE is a reliable method for the assessment of LVT before LVAD implantation.

306 - First-pass perfusion imaging to improve the assessment of left ventricular thrombus following a myocardial infarction

Abstract Purpose To assess whether a first-pass perfusion sequence (FPP) improved the detection of left ventricular thrombus (LVT). Materials and methods Three hundred and twenty-nine patients with a first STEMI were prospectively included to undergo cardiac magnetic resonance (CMR) at baseline and after a 3-month follow-up. A CMR delayed analysis was performed by three blinded examiners (2 CMR experts and 1 novice) according to a two-step reading protocol. First, an analysis was performed on cine CMR and late gadolinium enhancement (routine stage). Then, the FPP stage was performed following initial protocol along with a FPP sequence. Results LVT was found in 31 out of a total of 638 (4.9%) CMR scans, affecting 30 (9.1%) individuals. All were located in the left ventricular apex. The FPP stage improved significantly the LVT diagnosis for all readers, in 10 and 13 cases (32% and 42%) of LVT suspicion for the experts and 16 cases (41%) for the novice. Respectively 1, 2 and 6 LVT were not detected during the routine stage by the CMR experts and the novice. For the novice, the FPP stage improved diagnosis sensitivity from 78.1 to 91.2%. Conclusions The prevalence of LVT following a myocardial infarction reached 9.1% and increased with the reading of FPP sequence. The FPP stage improved expert diagnostic certitude and the novice’s abilities to reach expert level.

First pass perfusion imaging to improve the assessment of left ventricular thrombus following a myocardial infarction

PurposeTo assess whether a first-pass perfusion sequence (FPP) improved the detection of left ventricular thrombus (LVT). Materials and methodsThree hundred and twenty-nine patients with a first STEMI were prospectively included to undergo cardiac magnetic resonance (CMR) at baseline and after a 3-month follow-up. A CMR delayed analysis was performed by three blinded examiners (2 CMR experts and 1 novice) according to a two-step reading protocol. First, an analysis was performed on cine CMR and late gadolinium enhancement (routine stage). Then, the FPP stage was performed following initial protocol along with a FPP sequence. ResultsLVT was found in 31 out of a total of 638 (4.9%) CMR scans, affecting 30 (9.1%) individuals. All were located in the left ventricular apex. The FPP stage improved significantly the LVT diagnosis for all readers, in 10 and 13 cases (32% and 42%) of LVT suspicion for the experts and 16 cases (41%) for the novice. Respectively 1, 2 and 6 LVT were not detected during the routine stage by the CMR experts and the novice. For the novice, the FPP stage improved diagnosis sensitivity from 78.1 to 91.2%. ConclusionsThe prevalence of LVT following a myocardial infarction reached 9.1% and increased with the reading of FPP sequence. The FPP stage improved expert diagnostic certitude and the novice’s abilities to reach expert level.

Cardiac Imaging for Assessment of Left Ventricular Thrombus

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Hypereosinophilic syndrome with characteristic left ventricular thrombus demonstrated by contrast echocardiography

Hypereosinophilic syndrome (HES) is a rare condition characterised by idiopathic eosinophilia with organ system involvement. The condition is far more common in males, with a typical onset in the third to sixth decade. Cardiac damage may result in the formation of a characteristic apical thrombus readily visualised on two-dimensional echocardiography. Cardiac involvement portends a less favourable prognosis as it can be complicated by acute embolic events and progressive development of restrictive cardiomyopathy, valvular dysfunction, and heart failure. In this case report, we describe a middle-aged gentleman with HES and characteristic apical thrombus identified on contrast echocardiography. Although the use of contrast agents for assessment of left ventricular thrombus is documented in the literature,1 this case illustrates the application of contrast echocardiography in the evaluation of eosinophilia. (Neth Heart J 2009;17:169-70.).

Demonstration of Left Ventricular Thrombi with Real-time 3-Dimensional Echocardiography in a Patient with Cardiomyopathy

Two-dimensional echocardiography is a conventional tool to evaluate left ventricular thrombus but the use of real-time 3-dimensional echocardiography is not widespread. We report a 35-year-old man with unsuspected cardiomyopathy and a long history of both amphetamine and alcohol abuse. He presented with abdominal pain and right lower leg numbness and pain. Computed tomography revealed infarctions of the spleen and both kidneys, along with occlusion of the right femoral artery. Echocardiography demonstrated left ventricular systolic dysfunction and multiple large thrombi in the left ventricle. The thrombi had a specific dynamic pattern on real-time 3-dimensional echocardiography. The patient underwent surgical embolectomy of the right femoral artery and was anticoagulated. Two months later, the cardiac thrombi had totally disappeared.

Usefulness of Contrast Echocardiography for Assessment of Left Ventricular Thrombus After Acute Myocardial Infarction

Fifty consecutive patients referred to a coronary care unit for acute anterior myocardial infarction with ST-segment elevation underwent coronary arteriography, left ventricular (LV) angiography, and revascularization. Transthoracic echocardiography was systematically performed using fundamental imaging, second harmonic imaging, and contrast agents to assess the LV chamber. Six patients (12%) presented with a confirmed LV mural thrombus. Thirty-five percent of patients with time to revascularization>3 hours presented with an LV mural thrombus versus 0 patients with time to revascularization<or=3 hours (p=0.003). The most accurate method of detecting LV mural thrombus was contrast echocardiography regardless of physician experience. No patient with a misdiagnosis of thrombus had an optimal acoustic window using fundamental imaging or second harmonic imaging. In conclusion, patients presenting with acute anterior myocardial infarction could benefit from contrast echocardiography for assessment of LV mural thrombus when acoustic windows are suboptimal and time to revascularization is >3 hours.

Incremental Value of Live/Real Time Three‐Dimensional Transthoracic Echocardiography in the Assessment of Left Ventricular Thrombi

This is a case series on three adult patients who contain left ventricular (LV) thrombus and the incremental benefits of live/real time three-dimensional transthoracic echocardiography (3DTTE) in comparison to two-dimensional transthoracic echocardiography (2DTTE) in evaluating LV thrombi. These cases illustrate that 3DTTE is of additional benefit by demonstrating the following: (1) cropping of a single 3DTTE apical dataset may be enough to provide comprehensive assessment of the LV in a timely manner even without breath holding in a not fully cooperative patient (2) it identifies the exact point of attachment of the thrombus to the left ventricular wall, (3) helps to delineate the absence or presence of focal echolucent areas within thrombi indicative of the presence and extent of clot lysis, which may have potential therapeutic and prognostic implications, and (4) provides more accurate assessment of thrombus mobility which has prognostic indications.

Long-term prospective assessment of left ventricular thrombus in anterior wall acute myocardial infarction and implications for a rational approach to embolic risk

To prospectively assess the predictive value of left ventricular (LV) thrombus anatomy for defining the embolic risk after acute myocardial infarction (AMI), 2 comparable groups of patients with a first anterior AMI (group A, 97 thrombolysed patients; group B, 125 patients untreated with antithrombotic drugs [total 222]) underwent prospective serial echocardiography (follow-up 39 ±13 months) at different time periods. LV thrombi were detected in 26 patients in group A (27%) and in 71 in group B (57%; p <0.005). Embolism occurred in 12 patients (5.4%; 1 in group A [1%] vs 11% in group B [9%], p < 0.04). At multivariate analysis, thrombus morphologic changes were the most powerful predictor of embolism (p <0.001), followed by protruding shape (p <0.01) and mobility (p <0.02). In patients untreated with thrombolysis, a higher occurrence of thrombus morphologic changes (48% vs 8%, p <0.002) and protruding shape (69% vs 31%, p <0.002) were observed, whereas thrombus mobility was similar in the 2 groups (18% vs 8%, p = NS). Thrombus resolution occurred more frequently in thrombolysed patients (85% vs 56%, p <0.002). Thus, after anterior AMI, changes in LV thrombus anatomy frequently occur and appear the most powerful predictor of embolization. A minor prevalence of thrombus, a more favorable thrombus anatomy, and a higher resolution rate may contribute to reduce embolic risk after thrombolysis.