Imaging of intracardiac thrombus

A case report of right ventricular defibrillator and left bundle branch area leads placement and atrioventricular node ablation with chronic right ventricular thrombus

Despite lack of concrete evidence, right ventricular thrombus is generally considered to be a contraindication for intracardiac lead placement. We present a case of successful placement of a right ventricular defibrillator lead and left bundle branch pacing lead and atrioventricular node ablation in a patient with chronic right ventricle thrombus.

Massive Biventricular Thrombi in a Patient with Endometrial Adenocarcinoma Diagnosed on Computed Tomography Angiography

Biventricular thrombi are a rare clinical entity and only reported in several case reports. Given ventricular thrombi are high risk for cardioembolic events, accurate detection and therapeutic management has an important influence on clinical outcomes. We present a case of a patient with biventricular thrombi that was initially diagnosed on computed tomography angiography, emphasizing its clinical utility as a rapid, non-invasive imaging modality for early detection.

Ultrasonographic findings of abdominal thrombosis in dogs

ABSTRACT This retrospective case series study describes the clinical and vascular ultrasound findings of 26 dogs diagnosed with abdominal thrombosis. Images were selected based on the detection of intravascular echogenic thrombus or the absence of vascular flow on color Doppler, confirmed by surgery or necropsy. Images were acquired using the Mylab 40 model, with linear and microconvex multifrequency probes. All the reports were evaluated along with the corresponding images by a veterinary diagnostic imaging radiologist. The ultrasonographic aspects evaluated were echogenicity (92.3%), anechogenicity (7.7%), vascularization (11.5%), mineralization (15.4%), and recanalization (7.7%) of the thrombosis. The vascular and hemodynamic findings were dilation of the affected vein (57.7%), total occlusion of blood flow (30.8%), presence of turbulent flow (65.38%), and visualization of smoke signal (blood flow detected as moving echogenic points in dynamic bidimensional mode) (11.5%). Neoplasms (19 cases) and nephropathies (13 cases) were the most common clinical conditions in the affected dogs. Eleven cases of vascular invasion due to adrenal neoplasms were identified. The results indicate that the vascular ultrasound examination is an important method for diagnosis, as 23 of the 26 cases did not show any clinical signs of thrombosis.

Applications of multimodality imaging for left atrial catheter ablation

Atrial arrhythmias, including atrial fibrillation and atrial flutter, may be treated through catheter ablation. The process of atrial arrhythmia catheter ablation, which includes patient selection, pre-procedural planning, intra-procedural guidance, and post-procedural assessment, is typically characterized by the use of several imaging modalities to sequentially inform key clinical decisions. Increasingly, advanced imaging modalities are processed via specialized image analysis techniques and combined with intra-procedural electrical measurements to inform treatment approaches. Here, we review the use of multimodality imaging for left atrial ablation procedures. The article first outlines how imaging modalities are routinely used in the peri-ablation period. We then describe how advanced imaging techniques may inform patient selection for ablation and ablation targets themselves. Ongoing research directions for improving catheter ablation outcomes by using imaging combined with advanced analyses for personalization of ablation targets are discussed, together with approaches for their integration in the standard clinical environment. Finally, we describe future research areas with the potential to improve catheter ablation outcomes.

A case report of mass and pressure: the utility of contrast echocardiography

BACKGROUND

Diagnostic dilemmas in an unwell neonate can require the use of enhanced imaging modalities, especially in post-operative cardiac disease.

CASE SUMMARY

A neonate presented a diagnostic challenge following the repair of complex transposition of the great arteries, when an echogenic mass was noted in the region of the left atrial appendage on two-dimensional echocardiography, in the context of a monitoring line (left atrial line) inserted directly through this area. Although the pressure monitoring on this line suggested elevated left atrial pressure, the neonate was clinically and haemodynamically stable. Contrast echocardiography was used to investigate this further and found the mass to be extracardiac.

CONCLUSION

Contrast echocardiography is a simple and readily available tool for further echocardiographic delineation of structures, although needs to be performed carefully and the results interpreted logically.

Left Ventricular Apical Thrombus Mimicking Hypertrabeculation

A 73-year-old man visited our hospital due to dyspnea and epigastralgia. His plasma brain natriuretic peptide level was 1,205 pg/mL. A 12-lead electrocardiogram showed ST segment depression in leads I, V5, and V6. Transthoracic echocardiography showed dilatation and severe hypokinesis of the left ventricle. Hypertrabeculation was observed at the septum, apex, and lateral wall. Delayed enhancement of cardiac magnetic resonance imaging revealed a relatively low uptake of contrast agent at a large apical trabecula. After treatment with diuretics, follow-up echocardiography showed the disappearance of the controversial apical trabecula, which was later confirmed to have been a thrombus.

Left atrial thrombus in a case of severe aortic stenosis with severe left ventricular dysfunction: An Incidental finding on transesophageal echocardiography

Left atrial thrombus in a patient with aortic stenosis and aortic regurgitation in sinus rhythm is an infrequent finding and is most commonly associated with cases of mitral stenosis. This case report emphasizes upon the importance of suspecting the presence of left atrial thrombus in other valvular lesions when additional risk factors such as dilated left ventricle are present. The undeniable role of comprehensive perioperative transesophageal echocardiography is also depicted in this case report.

Cardiac computed tomography and magnetic resonance imaging vs. transoesophageal echocardiography for diagnosing left atrial appendage thrombi

Aims

Transoesophageal echocardiography (TOE) is the gold standard for identification of left atrial appendage (LAA) thrombi. However, TOE is semi-invasive and cannot be performed in certain patients. Left atrial appendage thrombi can also be identified by cardiac computed tomography (CCT) and cardiac magnetic resonance imaging (CMR); however, the diagnostic performance of these techniques vs. TOE is unclear.

Methods and results

We performed a systematic review and meta-analysis of 22 CCT and 4 CMR studies comparing diagnostic performance to TOE for identification of LAA thrombi. Meta-regression was performed to determine whether expected sensitivity and specificity differed between early and delayed image acquisition protocols for CCT vs. TOE and between CCT and CMR. Cardiac computed tomography demonstrated sensitivity and specificity of 0.99 [confidence interval (CI 0.93-1.00)] and 0.94 (CI 0.90-0.97) respectively vs. TOE. A subgroup analysis comparing early vs. delayed protocol CCT imaging was performed showing no significant differences in sensitivity (P-value = 0.17) however improved specificity of the delayed imaging protocols (P-value = 0.04). Cardiac magnetic resonance imaging demonstrated sensitivity and specificity of 0.80 (CI 0.63-0.91) and 0.98 (CI 0.97-0.99), respectively when compared to TOE. There was no significant difference in sensitivity or specificity between CMR and CCT (P-values 0.996 and 0.484, respectively).

Conclusion

Cardiac computed tomography and CMR had good to excellent sensitivity and specificity vs. TOE. Further, there was no significant difference in the sensitivity and specificity of CCT vs. CMR, suggesting that both modalities can be considered reasonable alternatives to TOE in the identification of LAA thrombi. Cardiac magnetic resonance imaging may be especially beneficial when TOE and CCT cannot be performed.

Blood Cyst of the Mitral Valve Diagnosed in an Adult after Systemic Thrombolysis

Blood cysts in valves are very rare entities in adults, which can be distinguished through their echocardiographic features. A 57-year-old woman developed sudden dyspnea while hospitalized in the context of urinary sepsis; high-risk pulmonary embolism was diagnosed and she was prescribed systemic thrombolysis. She persisted with fever raising the suspicion of bacterial endocarditis. Transthoracic echocardiography did not report any masses, but later transesophageal imaging revealed a vegetation that was finally characterized as a blood cyst of the mitral valve based on ultrasound features. The patient evolved satisfactorily and did not require surgery.

Role of Imaging for Suspected Cardiac Thrombus

PURPOSE OF REVIEW

Cardiac thrombus formation is a frequent complication of a variety of prevalent diseases. Embolism of cardiac thrombus has the potential to result in significant morbidity and mortality from cerebrovascular and peripheral vascular events.

RECENT FINDINGS

Echocardiography is the most commonly used imaging modality for diagnosing intracardiac thrombus. However, technological advances in computed tomography and magnetic resonance imaging have allowed newer noninvasive modalities to evolve into robust tools for the clinical evaluation of patients suspected of disease. Complimentary use of these imaging techniques is crucial in the diagnosis of cardiac thrombus and initiation of anticoagulation therapy.

Computed tomography imaging characteristics of primary atrial intimal sarcoma

We present a 36-year-old man who presented to our emergency department with acute onset shortness of breath and syncope. He was found to have a large left atrial mass on initial computed tomography (CT) which was confirmed by echocardiography. Tumor biopsy and attempted excision were performed, showing a primary cardiac spindle cell sarcoma that was unable to be resected, to which the patient eventually succumbed to. Spindle cell sarcomas of the heart are very rare primary cardiac tumors, with a variable, non-specific presentation. The most effective treatment is surgical resection, with chemotherapy and radiotherapy showing some benefit. Despite these treatments, the prognosis is poor. Given the uncommon nature of this tumor, the objective of this report is to demonstrate the clinical presentation and CT imaging characteristics of a case of primary cardiac spindle cell sarcoma, to raise awareness of this entity, and to increase the index of suspicion as a potential differential diagnosis to cardiac tumors seen on imaging.

Left atrial appendage mass

Left atrial (LA) masses are known to be associated with peripheral embolization. Accurate identification of etiology is crucial because treatment strategies may differ. We present the case of a young woman, who was initially diagnosed with a LA thrombus and anticoagulated. The diagnosis was revised to a primary cardiac tumor after review of the echocardiographic findings. Surgical excision revealed an atrial myxoma in an unusual location.

Magnetic resonance imaging of cardiovascular thrombi in children

Cardiovascular thrombosis is rare in children and usually occurs in the presence of predisposing conditions, such as indwelling vascular catheters, tumors, aneurysms, ventricular dysfunction, or after surgery. Clots can occur in the cardiac chambers, arteries or veins, or inside conduits. Detection of thrombi is feasible with a variety of magnetic resonance imaging (MRI) techniques, including unenhanced methods but also contrast-enhanced MR angiography. In this essay we illustrate the MRI appearance of cardiovascular thrombosis in children and suggest an imaging protocol based on our clinical experience.

Pitfalls and Misinterpretations of Cardiac Findings on PET/CT Imaging: A Careful Look at the Heart in Oncology Patients

Positron emission tomography (PET) computed tomography (CT) with 2-[fluorine-18] fluoro-2-deoxy-d-glucose (FDG) has been established as an effective modality for evaluation of cancer. Interpretations of patterns of physiologic ¹⁸F-FDG uptake by the heart is particularly difficult given the wide normal variations of ¹⁸F-FDG metabolic activity observed. Atypical patterns of focal or diffuse physiologic cardiac ¹⁸F-FDG uptake and post-therapeutic effects after radiation therapy, systemic diseases, or cardiomyopathy may also be confused with malignant disease on ¹⁸F-FDG PET/CT. In this article, we review the variations of normal cardiac ¹⁸F-FDG uptake observed in oncology patients and the appearances of other patterns of pathologic metabolic activity, related or not related to the malignancy being investigated, that may lead to false-negative and false-positive results.

Early intracardiac thrombus and pulmonary embolus after trauma

Here, we present the case of a patient with the findings of an early intracardiac thrombus and a pulmonary embolus after major trauma. A large clot was identified extending from the inferior vena cava into the right atrium and ventricle in the setting of preserved right ventricular function. Post-traumatic intracardiac thrombus is extremely rare and no comparable cases have previously been described in the absence of a congenital heart defect and obvious myocardial injury. Best practice afterpost-traumatic intracardiac thrombus is not well established but we found that early inferior vena cava filter placement and treatment with therapeutic coagulation resulted in clinical improvement, resolution of the thrombus and no further emboli. The successful use of rivaroxaban, a direct-acting oral anticoagulant, to treat a right heart thrombus has, to our knowledge, not previously been reported. Early acute traumatic coagulopathy has received much attention but the hypercoagulable state that often follows is less well appreciated.