Incidental left atrial and ventricular thrombi on routine CT: outcome and influence on subsequent management at an urban tertiary care referral center

Safety of dobutamine or adenosine stress cardiac magnetic resonance imaging in patients with left ventricular thrombus

BACKGROUND

Left ventricular (LV) thrombus formation is a common but potentially serious complication, typically occurring after myocardial infarction. Due to perceived high thromboembolic risk and lack of safety data, stress cardiac magnetic resonance (CMR) imaging especially with dobutamine is usually avoided despite its high diagnostic yield. This study aimed to investigate the characteristics, safety and outcome of patients with LV thrombus undergoing dobutamine or vasodilator stress CMR.

METHODS

Patients undergoing stress CMR with concomitant LV thrombus were retrospectively included. Risk factors, comorbidities, and previous embolic events were recorded. Periprocedural safety was assessed for up to 48 h following the examination. Major adverse cardiac events (MACE) 12 months before the diagnosis were compared to 12 months after the exam and between patients and a matched control group. Additionally, patients were followed up for all-cause mortality.

RESULTS

95 patients (78 male, 65 ± 10.7 years) were included. Among them, 43 patients underwent dobutamine (36 high-dose, 7 low-dose) and 52 vasodilator stress CMR. Periprocedural safety was excellent with no adverse events. During a period of 24 months, 27 MACE (14.7%) occurred in patients and controls with no statistical difference between groups. During a median follow-up of 33.7 months (IQR 37.6 months), 6 deaths (6.3%) occurred. Type of stress agent, thrombus mobility, or protrusion were not correlated to embolic events or death.

CONCLUSION

The addition of a stress test to a CMR exam is safe and does increase the generally high cardioembolic event rate in LV thrombus patients. Therefore, it is useful to support reperfusion decision-making.

Benign incidental cardiac findings in chest and cardiac CT imaging

With the continuous expansion of the disease scope of chest CT and cardiac CT, the number of these CT examinations has increased rapidly. In addition to their common indications, many incidental cardiac findings can be observed when carefully evaluating the coronary arteries, valves, pericardium, ventricles, and large vessels. These findings may have clinical significance or risk of complications, but they are sometimes overlooked or may not be described in the final reports. Although most of the incidental findings are benign, timely detection and treatment can improve the management of chronic diseases or reduce the possibility of severe complications. In this review, we summarized the imaging findings, incidence rate, and clinical relevance of some benign cardiac findings such as coronary artery calcification, aortic and mitral valve calcification, aortic calcification, cardiac thrombus, myocardial bridge, aortic dilation, cardiac myxoma, pericardial cyst, and coronary artery fistula. Reporting incidental cardiac findings will help reduce the risk of severe complications or disease deterioration and contribute to the recovery of patients.

Cardiac Imaging Within Emergency CT Angiography for Acute Stroke Can Detect Atrial Clots

Cardiac embolism is presumed to cause a significant portion of cryptogenic strokes. Transesophageal echocardiography may detect intracardiac thrombi, but this remains a rare finding, possibly because remnant clots dissolve spontaneously or following thrombolysis. Cardiac imaging within cerebral CT angiography might offer an alternative method for thrombus detection within hyperacute stroke assessment. In a proof-of-concept study we analyzed records of patients aged ≥ 60 years that presented with suspected stroke and underwent extended cerebral CT angiography as part of their emergency assessment. CT imaging of patients with ischemic stroke or transient ischemic attack (TIA) and atrial fibrillation and of those with embolic strokes of undetermined source (ESUS) was reviewed for intracardiac clots and other cardiac or aortic pathology. Over a period of 3 months 59 patients underwent extended CT angiography for suspected stroke, 44 of whom received a final diagnosis of ischemic stroke or TIA. Of those, 17 had atrial fibrillation, and four fulfilled ESUS criteria. Thrombi were detected within atrial structures on CT angiography in three cases. In two ESUS patients complex atheromatosis of the proximal ascending aorta with irregular and ulcerating plaques was detected. Cardiac imaging within emergency cerebral CT angiography is feasible and can provide valuable diagnostic information in a patient group that might not routinely undergo transesophageal echocardiography. A small change to emergency assessment could potentially uncover cardioembolic pathology in cases that would have remained cryptogenic otherwise.