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Curtis SF, Cicioni M, Mullikin A, Williams J, Campbell JM, Barker PCA, McCrary AW. Detection of occult thrombosis in individuals with Fontan circulation by cardiac MRI. Cardiol Young 2024:1-6. [PMID: 38506050 DOI: 10.1017/s1047951124000489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
OBJECTIVE Identifying thrombus formation in Fontan circulation has been highly variable, with reports between 17 and 33%. Initially, thrombus detection was mainly done through echocardiograms. Delayed-enhancement cardiac MRI is emerging as a more effective imaging technique for thrombus identification. This study aims to determine the prevalence of occult cardiac thrombosis in patients undergoing clinically indicated cardiac MRI. METHODS A retrospective chart review of children and adults in the Duke University Hospital Fontan registry who underwent delayed-enhancement cardiac MRI. Individuals were excluded if they never received a delayed-enhancement cardiac MRI or had insufficient data. Demographic characteristics, native heart anatomy, cardiac MRI measurements, and thromboembolic events were collected for all patients. RESULTS In total, 119 unique individuals met inclusion criteria with a total of 171 scans. The median age at Fontan procedure was 3 (interquartile range 1, 4) years. The majority of patients had dominant systemic right ventricle. Cardiac function was relatively unchanged from the first cardiac MRI to the third cardiac MRI. While 36.4% had a thrombotic event by history, only 0.5% (1 patient) had an intracardiac thrombus detected by delayed-enhancement cardiac MRI. CONCLUSIONS Despite previous echocardiographic reports of high prevalence of occult thrombosis in patients with Fontan circulation, we found very low prevalence using delayed-enhancement cardiac MRI. As more individuals are reaching adulthood after requiring early Fontan procedures in childhood, further work is needed to develop thrombus-screening protocols as a part of anticoagulation management.
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Affiliation(s)
- Samantha F Curtis
- Department of Internal Medicine-Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Mariah Cicioni
- Department of Pediatric, Duke University Medical Center, Durham, NC, USA
| | | | - Jason Williams
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - J Michael Campbell
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Piers C A Barker
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | - Andrew W McCrary
- Division of Pediatric Cardiology, Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
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2
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Chaosuwannakit N, Makarawate P. Left Ventricular Thrombi: Insights from Cardiac Magnetic Resonance Imaging. ACTA ACUST UNITED AC 2021; 7:180-188. [PMID: 34065998 PMCID: PMC8162548 DOI: 10.3390/tomography7020016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/21/2021] [Accepted: 05/04/2021] [Indexed: 11/16/2022]
Abstract
Objective: Cardiovascular magnetic resonance imaging (CMR) late gadolinium enhancement technique (LGE) detects thrombus rather than anatomical presence based on tissue properties and is theoretically highly accurate. The present study’s goal was to compare the diagnostic accuracy obtained with various CMR techniques and transthoracic echocardiography to diagnose left ventricular thrombus and evaluate the prevalence and perspectives of left ventricular (LV) thrombus among patients with impaired systolic left ventricular function. Methods: In a single academic referral center, a retrospective database review of all CMR assessments of the established left ventricular thrombus was carried out in 206 consecutive patients with reduced systolic function for five years. To assess thrombus risk factors, clinical and imaging parameters were analyzed. Sensitivity, specificity, negative predictive value (NPV), positive predictive value (PPV), echocardiography, and cine-CMR sequence accuracy have been identified. LV structural parameters were quantified to detect markers for thrombus and predictors of the additive usefulness of contrast-enhanced thrombus imaging. Comparisons against LGE-CMR were made, which was used as the standard. Results: A 7.8 percent prevalence of left ventricular thrombus was identified by LGE-CMR. Cine-CMR increased the diagnostic efficiency for echocardiographic thrombus identification in this group, with sensitivity increasing from 50 percent by echocardiography to 75 percent by cine-CMR (p = 0.008). Dark blood CMR (DB-CMR) has better sensitivity and accuracy than echocardiography (p < 0.001), comparable to cine-CMR. The transmural infarct size was an independent marker for thrombus after correction for the LVEF and LV volume while considering only CMR parameters. There were significantly higher embolic events (HR = 71.33; CI 8.31–616.06, p < 0.0001) in LV thrombus patients detected by LGE-CMR. Conclusion: CMR imaging was more sensitive to left ventricular thrombi identification compared with transthoracic echocardiography. An additional parameter available from LGE-CMR and shown as an independent risk factor for left ventricular thrombus is the myocardial scar.
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Affiliation(s)
- Narumol Chaosuwannakit
- Radiology Department, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand
- Correspondence:
| | - Pattarapong Makarawate
- Cardiology Unit, Internal Medicine Department, Faculty of Medicine, Khon Kaen University, Khon Kaen 40002, Thailand;
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3
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Janus SE, Al-Kindi SG, Rashid I, Hoit BD. Cystic left ventricular mass: the utility of transthoracic echocardiography and cardiac MRI. BMJ Case Rep 2021; 14:14/2/e239985. [PMID: 33637503 PMCID: PMC7919553 DOI: 10.1136/bcr-2020-239985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Accurate identification of left ventricular masses (LVM) can be challenging, and if incorrect, may have devastating consequences. While transthoracic echocardiography is often the first test to identify intracardiac masses, cardiac MRI (CMRI) allows for better anatomical definition and tissue characterisation. We present a case of a 51-year-old man who presented with 4 weeks of shortness of breath, found on echocardiogram to have severely reduced LV function and a 2.5×4.0 cm LVM with a hypolucent/cystic core. Due to the unusual appearance, CMRI was required for confirmation of an LV thrombus. This case highlights the importance of multimodality imaging in the discovery and identification of LVM.
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Affiliation(s)
- Scott E Janus
- Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Sadeer G Al-Kindi
- Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Imran Rashid
- Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio, USA
| | - Brian D Hoit
- Harrington Heart and Vascular Institute, University Hospitals Case Medical Center, Cleveland, Ohio, USA
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4
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An unusual left ventricular mass. JAAPA 2015; 28:62-3. [DOI: 10.1097/01.jaa.0000473376.40125.40] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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5
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Kim J, Weinsaft JW. Thrombosis and Prognosis Following ST-Elevation Myocardial Infarction: Left Ventricular Thrombus Assessment by Cardiac Magnetic Resonance. Circ Cardiovasc Imaging 2015; 8:e004098. [PMID: 26481163 DOI: 10.1161/circimaging.115.004098] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Jiwon Kim
- From the Departments of Medicine and Radiology, Weill Cornell Medical College, New York, NY
| | - Jonathan W Weinsaft
- From the Departments of Medicine and Radiology, Weill Cornell Medical College, New York, NY.
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Roifman I, Connelly KA, Wright GA, Wijeysundera HC. Echocardiography vs Cardiac Magnetic Resonance Imaging for the Diagnosis of Left Ventricular Thrombus: A Systematic Review. Can J Cardiol 2015; 31:785-91. [DOI: 10.1016/j.cjca.2015.01.011] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Revised: 01/21/2015] [Accepted: 01/21/2015] [Indexed: 10/24/2022] Open
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Athanasiadis A, Schneider B, Sechtem U. Role of Cardiovascular Magnetic Resonance in Takotsubo Cardiomyopathy. Heart Fail Clin 2013; 9:167-76, viii. [DOI: 10.1016/j.hfc.2012.12.011] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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8
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Left ventricular thrombus attenuation characterization in cardiac computed tomography angiography. J Cardiovasc Comput Tomogr 2012; 6:121-6. [PMID: 22342878 DOI: 10.1016/j.jcct.2011.12.006] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2011] [Accepted: 12/12/2011] [Indexed: 11/22/2022]
Abstract
BACKGROUND Because of their similar visual appearance, differentiation of left ventricular thrombotic material and myocardial wall can be difficult in contrast-enhanced coronary computed tomography (CT) angiography. OBJECTIVE We identified typical thrombi attenuation of left ventricular thrombi with the use of CT measurement. METHODS Over a time period of 6 years, we retrospectively identified 31 patients who showed a left ventricular thrombus in CT angiography datasets. Patients underwent routine contrast cardiac CT to investigate coronary artery disease. CT attenuation of each thrombus was assessed in the 4-chamber view. CT densities were also determined in the ascending aorta, left ventricle, and myocardial wall both in the mid-septal and mid-lateral segments. The mean CT attenuation of thrombi and the difference between attenuation in thrombi, left ventricular cavity, and myocardial wall were determined. The ratio of attenuation values in thrombus versus aorta and myocardium versus aorta were also determined. RESULTS Mean (±SD) CT attenuation of all left ventricular thrombi in 31 patients was 43.2 ± 15.3 HU (range, 25-80 HU). Mean CT densities of septal and lateral myocardial wall were 102.9 ± 23.1 HU (range, 63-155 HU) and 99.3 ± 28.7 HU (range, 72-191 HU), respectively, and were thus significantly higher than the CT attenuation of thrombi (P < 0.001). A threshold of 65 HU yielded a sensitivity, specificity, and positive and negative predictive values of 94%, 97%, 94%, and 97%, respectively, to differentiate thrombus from the myocardial wall. The mean ratio between CT attenuation of thrombus and CT attenuation within the ascending aorta was 0.11 ± 0.05 (range, 0.04-0.23), which was significantly lower compared with the mean ratio between CT attenuation of the myocardial wall and the CT attenuation within the ascending aorta. CONCLUSION CT attenuation within left ventricular thrombi was significantly lower than myocardial attenuation in CT angiography datasets. Assessment of CT attenuation may contribute to the differentiation of thrombi.
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Popescu BA, Andrade MJ, Badano LP, Fox KF, Flachskampf FA, Lancellotti P, Varga A, Sicari R, Evangelista A, Nihoyannopoulos P, Zamorano JL, Derumeaux G, Kasprzak JD, Roelandt JR. European Association of Echocardiography recommendations for training, competence, and quality improvement in echocardiography. EUROPEAN JOURNAL OF ECHOCARDIOGRAPHY 2009; 10:893-905. [DOI: 10.1093/ejechocard/jep151] [Citation(s) in RCA: 154] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Gastwirth JL, Gel YR, Miao W. The Impact of Levene’s Test of Equality of Variances on Statistical Theory and Practice. Stat Sci 2009. [DOI: 10.1214/09-sts301] [Citation(s) in RCA: 224] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Smith W, Adams D, Kisslo J. Intracardiac Masses. Echocardiography 2009. [DOI: 10.1007/978-1-84882-293-1_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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12
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Weinsaft JW, Kim HW, Shah DJ, Klem I, Crowley AL, Brosnan R, James OG, Patel MR, Heitner J, Parker M, Velazquez EJ, Steenbergen C, Judd RM, Kim RJ. Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction. J Am Coll Cardiol 2008; 52:148-57. [PMID: 18598895 DOI: 10.1016/j.jacc.2008.03.041] [Citation(s) in RCA: 201] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2007] [Revised: 02/06/2008] [Accepted: 03/04/2008] [Indexed: 12/31/2022]
Abstract
OBJECTIVES This study sought to assess the prevalence and markers of left ventricular (LV) thrombus among patients with systolic dysfunction. BACKGROUND Prior studies have yielded discordant findings regarding prevalence and markers of LV thrombus. Delayed-enhancement cardiovascular magnetic resonance (DE-CMR) identifies thrombus on the basis of tissue characteristics rather than just anatomical appearance and is potentially highly accurate. METHODS Prevalence of thrombus by DE-CMR was determined in 784 consecutive patients with systolic dysfunction (left ventricular ejection fraction [LVEF] <50%) imaged between July 2002 and July 2004. Patients were recruited from 2 separate institutions: a tertiary-care referral center and an outpatient clinic. Comparison to cine-cardiovascular magnetic resonance (CMR) was performed. Follow-up was undertaken for thrombus verification via pathology evaluation or documented embolic event within 6 months after CMR. Clinical and imaging parameters were assessed to determine risk factors for thrombus. RESULTS Among this at-risk population (age 60 +/- 14 years; LVEF 32 +/- 11%), DE-CMR detected thrombus in 7% (55 patients) and cine-CMR in 4.7% (37 patients, p < 0.005). Follow-up was consistent with DE-CMR as a better reference standard than cine-CMR, including 100% detection among 5 patients with thrombus verified by pathology (cine-CMR, 40% detection), and logistic regression analysis testing the contributions of DE-CMR and cine-CMR simultaneously, which showed that only the presence of thrombus by DE-CMR was associated with follow-up end points (p < 0.005). Cine-CMR generally missed small intracavitary and small or large mural thrombus. In addition to traditional indices such as low LVEF and ischemic cardiomyopathy, multivariable analysis showed that increased myocardial scarring, an additional parameter available from DE-CMR, was an independent risk factor for thrombus. CONCLUSIONS In a broad cross section of patients with systolic dysfunction, thrombus prevalence was 7% by DE-CMR and included small intracavitary and small or large mural thrombus missed by cine-CMR. Prevalence increased with worse LVEF, ischemic etiology, and increased myocardial scarring.
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Affiliation(s)
- Jonathan W Weinsaft
- Duke Cardiovascular Magnetic Resonance Center, Duke University Medical Center, Durham, North Carolina 27710, USA
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Douglas P, Iskandrian AE, Krumholz HM, Gillam L, Hendel R, Jollis J, Peterson E, Chen J, Masoudi F, Mohler E, McNamara RL, Patel MR, Spertus J. Achieving Quality in Cardiovascular Imaging. J Am Coll Cardiol 2006; 48:2141-51. [PMID: 17113004 DOI: 10.1016/j.jacc.2006.06.076] [Citation(s) in RCA: 103] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2006] [Revised: 06/26/2006] [Accepted: 06/26/2006] [Indexed: 11/26/2022]
Abstract
Cardiovascular imaging has enjoyed both rapid technological advances and sustained growth, yet less attention has been focused on quality than in other areas of cardiovascular medicine. To address this deficit, representatives from cardiovascular imaging societies, private payers, government agencies, the medical imaging industry, and experts in quality measurement met, and this report provides an overview of the discussions. A consensus definition of quality in imaging and a convergence of opinion on quality measures across imaging modalities was achieved and are intended to be the start of a process culminating in the development, dissemination, and adoption of quality measures for all cardiovascular imaging modalities.
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Affiliation(s)
- Pamela Douglas
- Duke University Medical Center 3943, Duke North 7451, Durham, North Carolina 27710, USA.
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Crawford TC, Smith WT, Velazquez EJ, Taylor SM, Jollis JG, Kisslo J. Prognostic usefulness of left ventricular thrombus by echocardiography in dilated cardiomyopathy in predicting stroke, transient ischemic attack, and death. Am J Cardiol 2004; 93:500-3. [PMID: 14969636 DOI: 10.1016/j.amjcard.2003.10.056] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2003] [Revised: 10/16/2003] [Accepted: 10/16/2003] [Indexed: 11/15/2022]
Abstract
Echocardiograms of 290 patients with dilated cardiomyopathy (ejection fraction < or =35%) were reviewed for the presence of left ventricular (LV) apical abnormalities; outcomes of stroke and death were then correlated with the presence of LV thrombus. During a follow-up of 31 months, 15 patients had a stroke or transient ischemic attack after the index echocardiogram (5.2%). Patients with LV thrombus on echocardiography had a significantly higher rate of stroke (adjusted odds ratio 3.4, p = 0.027) than those without echocardiographic evidence of thrombi. There was no difference in mortality between patients with and without thrombus (20.9% vs 21.1%, p = 0.726).
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Affiliation(s)
- Thomas C Crawford
- Department of Cardiology, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
Transoesophageal echocardiography has proved to be a valuable monitor of global and regional ventricular function in the perioperative period. In addition, it is increasingly used by anaesthetists as a diagnostic tool in patients with heart disease. During the past year, important steps towards quality assurance and the standardization of perioperative echocardiography were undertaken, and our understanding of the perioperative cardiovascular structure and function improved.
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Affiliation(s)
- K Skarvan
- Department of Anaesthesia, University of Basel, Switzerland.
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