Left Ventricular Mural Thrombus Research Articles

Association between Mitral Regurgitation and Left Ventricular Mural Thrombi following Anterior ST Segment Elevation Myocardial Infarction

Association between Mitral Regurgitation and Left Ventricular Mural Thrombi following Anterior ST Segment Elevation Myocardial Infarction

Acute Occlusion of the Abdominal Aorta Associated with Left Ventricular Thrombus: A Case Report.

BACKGROUND Acute aortic occlusion (AAO) is a rare emergency with high mortality. The typical clinical presentation is the sudden appearance of pain, paralysis, sensory disturbances, and mottling of the lower extremities. The etiology of AAO can be broadly classified into 3 categories: in situ thrombosis, arterial embolism, and occlusion of grafts. AAO is a rare consequence of myocardial infarction in the era of anticoagulation therapy, as part of the management of acute coronary syndrome (ACS). CASE REPORT We report the case of a 65-year-old woman who presented with acute lower extremity pain and weakness after a myocardial infarction 2 weeks earlier. She was on standardized antiplatelet therapy, a high blood D-dimer level was found during a visit to the Emergency Department, a left ventricular mural thrombus was detected using bedside ultrasound, and computed tomography angiography revealed thrombotic occlusion of the abdominal aorta. AAO disease was diagnosed, but the patient refused further treatment and died after 7 days of follow-up. CONCLUSIONS In recent years, anticoagulation has become part of the standard of care for patients with myocardial infarction or atrial fibrillation, which has led to a lower incidence of arterial embolism leading to AAO than in situ thrombosis. Depending on the type of occlusion, there are also differences in the surgical approach. A computed tomography angiography of the abdomen should be performed on all patients in whom AAO cannot be ruled out. Timely diagnosis and prompt surgical intervention are essential to preventing mortality.

Left ventricular mural thrombus appearing as a photopenic defect on myocardial viability PET imaging

Left ventricular mural thrombus appearing as a photopenic defect on myocardial viability PET imaging

Transmitral extraction of a huge left ventricular mural thrombus using a novel mitral leaflet retractor

A 52‐year‐old woman with a past history of anterior myocardial infarction 15 years previously was found to have a pedunculated mobile thrombus with a narrow stalk originating from the left ventricle, and a huge laminated mural thrombus. Surgical extraction of the two organized thrombi was successfully performed with transmitral approach using a novel, flexible, self‐retained, and reusable leaflet retractor, which was originally developed for exposure of the subvalvular apparatus during mitral valve repair. Excellent access, exposure, and visualization of the left ventricle were achieved by this heart valve retractor and an endoscope for removal of a huge mural thrombus.

Major bleeding under enoxaparin treatment. An unexpected second offender

Admitted to hospital with an ischemic stroke, a 63-year-old male was diagnosed with a left ventricular mural thrombus. Enoxaparin treatment was started. Over 6 weeks there were two episodes of major hemorrhage needing brief discontinuation of anticoagulation. A previously normal prothrombin time (PT) became prolonged upon which vitamin K deficiency was diagnosed. The deficiency was caused by enteral feeding using a formula which did not contain the required daily dose of vitamin K. A triple message emerges from this observation: theneed for monitoring the PT in patients receiving enteral feeding, more so in those receiving anticoagulant along with enteral feeding, and the appeal to fortify feeding formulas with vitamin K.

Localization of focus by 18 F-fludeoxyglucose positron emission tomography computed tomography in the definitive diagnosis of infective endocarditis

18 F-fludeoxyglucose positron-emission tomography computed tomography scans are helpful in making definitive diagnosis of infective endocarditis (IE) in some selected cases. We are reporting two cases of IE, in one case, the infective focus was in the organized left ventricular mural thrombus and the second case the infective focus was found in the aortic root and annulus and the prosthetic valve was spared. This being a noninvasive test can be repeated to ascertain the adequacy of treatment during follow-up.

P585Intra left ventricular hemodynamics assessed using 4D flow MRI in the patient with left ventricular thrombus

Abstract Background Early detection of left ventricular mural thrombus (LVT) in patients with reduced ejection fraction (EF) is crucial in prevention of arterial embolism. 3D-cine phase-contrast magnetic resonance imaging (4D flow MRI) can visualize the intra-LV vortex flow in diastole and quantify the maximum flow velocity (Vmax) at the apex. it remains, however, unknown whether 4D flow MRI is useful for detecting LVT. Purpose The purpose of our study is to examine the intra-LV vortex formation and flow velocity in patients with severe LV dysfunction using 4D Flow MRI, and to compare differences in intra-LV flow dynamics between patients with and without LVT. We also examined the diagnostic accuracy to detect LVT by 4D flow MRI. Methods Twenty-nine patients with impaired LV function (LVEF 25.8±7.4%, 62.5±12.3 years old, 24 males, 11 with ischemic cardiomyopathy, 9 with LVT) underwent 4D flow MRI from January 2012 to August 2018 in our institution. Intra-LV vortex size was evaluated as vortex/LV area ratio by streamline imaging (Figure 1). The diagnostic accuracy to predict LVT by vortex size and Vmax at the apex was determined by ROC analysis. Results The vortex was smaller (vortex/LV area ratio; 30.6±7.0% vs. 45.1±9.0%, p<0.05) and Vmax at the apex was lower (0.20±0.04 m/s vs. 0.28±0.09 m/s, p=0.013) in patients with LVT compared to those without LVT. The AUC was 0.789 for Vmax (cut-off value=0.226 m/s, sensitivity=0.889, specificity=0.650) and was 0.900 for vortex/LV area ratio (cut-off value=34.7%, sensitivity=0.889, specificity=0.850). Figure 1 Conclusion The smaller size of intra-LV vortex and the lower flow velocity at the LV apex may have association with LVT formation in patients with reduced EF. 4D flow MRI might be useful to predict LVT formation. Large scale longitudinal study is warranted to evaluate the incidence of LVT in the patients with lower flow velocity. Acknowledgement/Funding None

Black-blood cinematic rendering: A new method for cardiac CT intraluminal visualization

BackgroundCinematic rendering (CR) is a method of generating photorealistic 3D images from volumetric computed tomography (CT) data. In this manuscript, we describe a CR preset we have termed black-blood cinematic rendering (BBCR) that allows for detailed endoluminal views of the heart. MethodsThree recent chest CT scans were retrospectively selected as representative examples for BBCR visualization. All scans had been performed with our institution's clinical standard, post-contrast, cardiac-gated chest CT. The BBCR images were created from isotropic-voxel reconstructed volumetric data on a stand-alone workstation. ResultsThe BBCR technique was successfully utilized to demonstrate intraluminal cardiac findings in a patient with a normal left ventricle, a patient with a left ventricular mural thrombus, and a patient status-post transcatheter aortic valve replacement. ConclusionsBBCR is a new method of utilizing volumetric chest CT data in order to provide detailed images of intraluminal anatomy and pathology of the heart. Further study of this promising method is warranted.

Left ventricular mural thrombus and dual coronary embolization associated with hyperthyroid cardiomyopathy and atrial fibrillation: a case report

BackgroundThe majority of acute myocardial infarction (AMI) events are caused by thrombotic occlusion of the coronary artery, secondary to atherosclerotic plaque erosion or rupture. However, coronary embolism (CE), while rare, is being increasingly recognized as an important cause of AMI. We present the case of a patient with multi-site coronary artery embolization associated with hyperthyroid-related cardiomyopathy and atrial fibrillation.Case presentationA 49-year-old female with a history of hyperthyroidism and atrial fibrillation (AF) was admitted to our hospital presenting with right upper limb pain and swelling. Initial transthoracic echocardiography demonstrated left ventricular apical mural thrombi and hyperthyroidism-induced cardiomyopathy. On the eighth day after admission, the patient developed sudden onset of severe chest pain and evidence of acute myocardial infarction (AMI). Emergency coronary angiography revealed multi-site coronary embolization of the left anterior descending artery and a large diagonal branch. Despite emergency thrombo-aspiration and balloon angioplasty, the patient went into ventricular fibrillation, from which she did not recover.ConclusionAlthough rare, a fatal case of left ventricular thrombus and dual-vessel coronary embolism associated with hyperthyroid cardiomyopathy and atrial fibrillation is reported.

Prognostic biomarkers in acute coronary syndrome.

The acute coronary syndrome (ACS) is a leading cause of death around the globe. Beside a still high mortality rate, additional complications of ACS include arrhythmias, left ventricular mural thrombus, cardiac fibrosis, heart failure (HF), cardiogenic shock, mitral valve dysfunction, aneurysms, up to cardiac rupture. Despite many prognostic tools have been developed over the past decades, efforts are still ongoing to identify reliable and predictive biomarkers, which may help predict the prognosis of these patients and especially the risk of HF. Recent evidence suggests that the value of a discrete number of biomarkers of myocardial fibrosis, namely the soluble form of suppression of tumorigenicity 2 (sST2) and galectin-3 (GAL-3), may be predictive of HF and death in patients with ACS. Interestingly, the already promising predictive value of these biomarkers when measured alone was shown to be consistently magnified when combined with other and well-established cardiac biomarkers such natriuretic peptides and cardiac troponins. This article is hence aimed to review the current knowledge about cardiac biomarkers of fibrosis and adverse remodeling.

Usefulness of the Left Anterior Descending Coronary Artery Wrapping Around the Left Ventricular Apex to Predict Adverse Clinical Outcomes in Patients With Anterior Wall ST-Segment Elevation Myocardial Infarction (from the Harmonizing Outcomes With Revascularization and Stents in Acute Myocardial Infarction Trial)

The association between anatomic features of the left anterior descending artery (LAD) and outcomes in patients with anterior ST-segment elevation myocardial infarction (STEMI) has not been fully investigated. We sought to clarify the impact of an LAD coronary artery wrapping around the left ventricular (LV) apex on clinical outcomes in patients with anterior STEMI. Harmonizing Outcomes with Revascularization and Stents in Acute Myocardial Infarction enrolled patients with STEMI presenting <12 hours after symptom onset who underwent primary percutaneous coronary intervention. Patients with a culprit lesion in the LAD were categorized as (1) LAD wrapping around the LV apex (wrap-around LAD, n = 871) versus (2) LAD not wrapping around the LV apex (non-wrap-around LAD, n = 224). Killip class ≥II, dysrhythmia, and LV mural thrombi were more frequently observed in the wrap-around LAD group; LV ejection fraction was worse in the wrap-around LAD group (54.5% vs 58.7%, p = 0.006). At 3 years of follow-up, major adverse cardiac events (death, stroke, or stent thrombosis, 12.7% vs 5.4%, p = 0.002), death (6.6% vs 3.2%, p = 0.052), stroke (1.9% vs 0.5%, p = 0.12), stent thrombosis (5.6% vs 2.3%, p = 0.047), and severe heart failure (4.5% vs 1.4%, p = 0.03) were more common in patients with a wrap-around LAD versus those with a non-wrap-around LAD. Multivariate analysis indicated that a wrap-around LAD independently and significantly predicted major adverse cardiac events (hazard ratio 2.18, p = 0.02) and severe heart failure (odds ratio 3.31, p = 0.049) in patients with an anterior STEMI. In conclusion, a wrap-around LAD predicted adverse clinical outcomes at 3 years in patients with anterior STEMI who underwent primary percutaneous coronary intervention.

Prevalence and risk factors of embolic cerebrovascular events associated with Chagas heart disease.

Patients with Chagas disease are at increased risk for stroke that may result in major clinical disability and death. Identification of risk factors involved in the genesis of thromboembolic events related to this disease may lead to improved therapeutic decision making and outcomes. This study sought to assess the prevalence of ischemic cerebrovascular events (ICE) among patients with Chagas heart disease and to identify the risk factors associated with cardioembolism in this population. This study involved 330 patients, 193 were men (58%), with a mean age of 49 ± 12 years with Chagas disease classified in the chronic cardiac form of the disease. Comprehensive echocardiography was performed to search a substrate for cardioembolic events, especially apical aneurysm and intracavitary thrombus. Most of the patients were classified as New York Heart Association classes I or II (75%) with mean left ventricular (LV) ejection fraction of 39 ± 14%. Sixty-seven patients had a previous ICE with the overall prevalence of 20%. Apical aneurysms were detected in 128 patients (39%), whereas LV mural thrombi were found in 48 patients (15%). In multivariate analysis including the potential predictors of ICE, apical aneurysm (adjusted odds ratio [OR]: 2.19, 95% confidence interval [CI]: 1.11 to 4.34; p= 0.024) and LV thrombus (adjusted OR: 2.43, 95% CI: 1.09 to 5.42; p= 0.030) emerged as important determinants of ICE, after adjusting for anticoagulation therapy. In a selected population referred to a tertiary center for Chagas disease that included patients with different severities of cardiac involvement, the prevalence of ICE was 20%. The presence of apical aneurysm and intracavitary thrombus were independently associated with ICE, after adjustment for other risk factors for stroke.

Abrupt change in the shape of a left ventricular mural thrombus after intra-aortic balloon pump-supported percutaneous coronary intervention in recent myocardial infarction

A 77-year-old woman was diagnosed with congestive heart failure and broad anterior acute myocardial infarction that had occurred 10 days prior to her presentation in our hospital. A flat and immobile thrombus was widely attached to the luminal surface of the left ventricular antero-apical wall with dyskinetic motion. For treatment-resistant heart failure, the patient underwent percutaneous coronary intervention (PCI), with intravenous heparin, supporting an intra-aortic balloon pump. Echocardiography obtained 3h after the procedure revealed that the left ventricular mural thrombus had changed to a centrally hollow, ball-like shape of 4cm in diameter. The thrombus was surgically removed and left ventriculo-plasty was simultaneously performed without any systemic embolic events. Physicians should be aware that a relatively fresh left ventricular mural thrombus, even with no protrusion or immobility, may peel away from the endocardium after introducing an intra-aortic balloon pump under an optimal anticoagulation for performing PCI.<Learning objective: When determining the therapeutic strategy for congestive heart failure following a recent myocardial infarction with a large, fresh mural thrombus in a left ventricular aneurysm, physicians should be aware that the thrombus, even with no protrusion or immobility, may peel away from the endocardium.>

Comparison of the Usefulness of Enoxaparin Versus Warfarin for Prevention of Left Ventricular Mural Thrombus After Anterior Wall Acute Myocardial Infarction

Left ventricular (LV) thrombus is one of the most common complications in patients with anterior acute myocardial infarction (AMI) and LV dysfunction. Although anticoagulation is frequently prescribed, data regarding the appropriate drug, duration, risks, and effect on echocardiographic indices of thrombus are lacking. Moreover, given the difficulty in obtaining adequate anticoagulation with warfarin, it is possible that short-term treatment with a more predictable agent would be effective. We randomized 60 patients at high risk of developing LV mural thrombus (anterior acute myocardial infarction with Q waves and ejection fraction≤40%) to receive either enoxaparin 1 mg/kg (maximum 100 mg) subcutaneously every 12 hours for 30 days or traditional anticoagulation (intravenous heparin followed by oral warfarin for 3 months). Clinical evaluations and transthoracic echocardiograms were obtained at baseline, in-hospital, and at 3.5 months. There were no differences between the groups regarding baseline demographics, acute echocardiographic findings, and in-hospital outcomes. The length of hospital stay tended to be shorter for the enoxaparin group (4.6 vs 5.6; p=0.066) and the corresponding hospital costs ($25,837 vs $34,666; p=0.18). At 3 months, bleeding and thromboembolic events were rare and similar between enoxaparin and warfarin groups. Although more patients had probable mural thrombus in the enoxaparin group compared with warfarin at 3.5 months (15% vs 4%; p=0.35), this was not significantly different. In conclusion, the use of enoxaparin tends to shorten hospitalization and lower cost of care. However, at 3.5 months, there appears to be numerically higher (but statistically insignificant) rates of LV thrombus in the enoxaparin group.

Left Ventricular Mural Thrombus Treated With Dabigatran

Novel oral anticoagulants may be effective and safe alternatives to conventional treatment for left ventricular (LV) mural thrombus. A case of left ventricular mural thrombus successfully treated with dabigatran etixelate is described, and the rationale for undertaking further systematic evaluation of novel anticoagulants for this indication discussed.

Ehokardiografija u akutnom koronarnom sindromu

Echocardiography is a non-invasive diagnostic technique for the management of patients with chest pain. The challenge for the physicians is to identify patients with atypical symptoms or non-diagnostic electrocardiogram changes. Echocardiography is very useful in triage of patients with acute chest pain or dyspnea. An echocardiogram can also help in defining of localisation and extension of an infarction and in assessing overall function of the left and right ventricules. It has also been used in risk stratification after myocardial infarction and to evaluate reperfusion therapies. In additon, an echocardiogram can help to identify complications, such as acute mitral regurgitation, left ventriculy rupture, pericardiale effusion, intraventricular septum rupture and left ventricular mural thrombus formation. Transthoracic echocardiography provides a quick and cheap bed side method of diagnosis and evaluation patients with acute coronary syndrome.

Accessory Left Ventricular Chamber

Accessory Left Ventricular Chamber

Multiple cardiovascular complications in a patient with missed small apical myocardial infarction caused by a coronary artery thrombus of uncertain origin

An 82 year-old hypertensive male with no concomitant diseases was admitted because of missed myocardial infarction (MI), 3 days after chest pain onset. On admission, the patient was pain free with stable haemodynamics and normal physical examination. The ECG (Fig. 1) showed atrial fibrillation (AF) and ischaemic changes with its resolution at follow-up. During coronarography (Fig. 2), the presence of a thrombus in the apical part of the left anterior descending (LAD) artery, atherosclerotic plaques with lack of culprit lesion clearly connected to the thrombus, and insignificant myocardial bridging (MB) were demonstrated. The patient was followed conservatively. Troponin and CK-MB elevation with decreasing consecutive values was observed. Transthoracic echocardiography (TTE) delineated left atrial (LA) enlargement, akinesia limited to the left ventricular apex with preserved global ejection fraction of 60% as well as a recent, partially movable, apical left ventricular mural thrombus (LVMT) (Fig. 3A). Warfarin therapy was introduced. On day 2, he developed acute ischaemic stroke (AIS). Carotid artery disease was excluded. On day 6, a systolic murmur demonstrated by echocardiography as an apical ventricular septal rupture (VSR) with left-to-right shunt and a thrombus partially occluding the defect which was smaller and less movable was diagnosed (Fig. 3B). The cardiothoracic surgeon recommended delaying surgical treatment. The patient’s haemodynamic status worsened gradually with signs of exclusive right ventricular failure. An intra-aortic balloon pump was not used due to lack of patient co-operation. On day 18, the family requested that he be discharged home where he finally died. It is most likely that atherosclerotic plaque was involved in the thrombus formation and coronary occlusion, although an AF related embolism is quite possible. These hypotheses could not be verified because there was no culprit lesion and no LA thrombus confirmation. Less probably, MB could have given rise to coronary thrombosis with subsequent MI. Finally, tako-tsubo cardiomyopathy, coronary vasospasm or MB can be a primary cause of apical akinesia, blood stagnation, LVMT development and secondary coronary embolism. LVMT and VSR are strongly associated with extensive anterior MI. In this case it was small and limited to the apex, but proximal LAD occlusion with downstream thrombus migration is possible. Moreover, we speculate that ST elevation in inferior leads might be related to dominant LAD and that ST depression in precordial leads might be a reciprocal change. A coincidence of LVMT and VSR has rarely been documented. Moreover, we observed the partial occlusion of the defect by the thrombus which might delay its recognition and slow the natural evolution. The most probable explanation for AIS is embolisation related to recent LVMT or AF.

035 INCIDENCE AND PREDICTORS OF LEFT VENTRICULAR MURAL THROMBUS AFTER ST-ELEVATION MYOCARDIAL INFARCTION IN THE CONTEMPORARY ERA OF PRIMARY PCI

Background In patients presenting with ST elevation myocardial infarction (STEMI), early and aggressive reperfusion therapy increases myocardial salvage and improves survival. Left ventricular mural thrombus (LVT) is more likely to occur after full thickness infarction. The aim of this study was to define the incidence of LVT and its predictors in the contemporary era of effective primary percutaneous coronary intervention (PCI). Methods We retrospectively analysed 1220 patients with STEMI admitted directly to our centre for primary PCI (1 January 2009–31 August 2012). Patients received dual antiplatelet and anticoagulant therapy at the operator9s discretion (unfractionated heparin, bivalirudin and/or abciximab). A transthoracic echocardiogram (TTE) was performed in all cases prior to discharge. Echo-contrast was used when appropriate. Results LVT was detected by TTE in 41 patients (3.9%). There were no significant differences in baseline demographic in patients with and without LVT. LV systolic function, an anterior location of infarction and apical akinesis all predicted LVT. Univariate analysis also demonstrated a relationship between LVT and ejection fraction (EF). Mean EF in patients with LVT was 34% (95% CI 31.7 to 36.6); without LVT EF was 48% (95% CI 47% to 48.6%) p Conclusions In the contemporary era of primary PCI, the incidence of LVT in patients with STEMI is significantly lower than the previous literature suggests. Formation of LVT is predicted by anterior location of MI, reduced LV systolic function and the presence of an apical akinetic segment.

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.