Prognostic significance and natural history of left ventricular thrombi in patients with acute anterior myocardial infarction: a two-dimensional echocardiographic study

Left ventricular thrombosis caused cerebral embolism during venoarterial extracorporeal membrane oxygenation support: A case report

BACKGROUND

Venoarterial (VA) extracorporeal membrane oxygenation (ECMO), an effective short-term circulatory support method for refractory cardiogenic shock, is widely applied. However, retrospective analyses have shown that VA-ECMO-assisted cases were associated with a relatively high mortality rate of approximately 60%. Embolization in important organs caused by complications of left ventricular thrombosis (LVT) during VA-ECMO is also an important reason. Although the incidence of LVT during VA-ECMO is not high, the consequences of embolization are disastrous.

CASE SUMMARY

A 37-year-old female patient was admitted to hospital because of fever for 4 d and palpitations for 3 d. After excluding the diagnosis of coronary heart disease, we established a diagnosis of "clinically explosive myocarditis". The patient still had unstable hemodynamics after drug treatment supported by VA-ECMO, with heparin for anticoagulation. On day 4 of ECMO support, a left ventricular thrombus attached to the papillary muscle root of the mitral valve was found by transthoracic echocardiography. Left ventricular decompression was performed and ECMO was successfully removed, but the patient eventually died of multiple cerebral embolism.

CONCLUSION

LVT with high mobility during VA-ECMO may cause embolism in important organs. Therefore, a "wait and see" strategy should be avoided.

Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge

Although the management of ischaemic heart disease has markedly improved over the last decades, left ventricular thrombus remains a serious finding in patients with myocardial infarction. Routine diagnostic detection of left ventricular thrombus relies mainly on echocardiography; however, cardiac magnetic resonance has emerged as a method with higher diagnostic accuracy, while cardiac computed tomography angiography represents a valuable alternative modality. To reduce the left ventricular thrombus-associated morbidity and mortality, optimal selection of anticoagulation is warranted after balancing the risk of bleeding. In this review, we will discuss contemporary diagnostic modalities to detect left ventricular thrombus in ischaemic heart disease and summarize evidence on risk stratification and therapy. In addition, we propose a novel diagnosis, follow-up imaging, and treatment algorithm. Further, we identify knowledge gaps at different levels to address emerging research questions and to refine the design of future studies aiming to improve the management of patients in this clinical setting.

Outcomes of left ventricular thrombosis in post-acute myocardial infarction patients stratified by antithrombotic strategies: A meta-analysis with meta-regression

BACKGROUND

Left ventricular thrombus (LVT) formation is a significant complication of acute myocardial infarction (AMI) due to its embolic potential. However, managing LVT requires balancing therapeutic benefits against bleeding risks. Our study provides a risk-benefit analysis of various antithrombotic regimens on long-term outcomes in treating post-AMI LVT patients.

METHODS

We conducted a comprehensive literature search in Medline, Embase and SCOPUS up to 1 April 2020. All studies reporting outcomes of post-AMI LVT patients were included.

RESULTS

17 studies were included in total. Anticoagulation (47-100%) and triple therapy use (38-100%) varied largely across studies. On meta-analysis, administration of anticoagulation (OR 0.14, 95% CI 0.05-0.36, p < 0.001) and triple therapy (OR 0.22, 95% CI 0.07-0.66, p < 0.001) resulted in lower odds of mortality. Neither anticoagulation (p = 0.24) nor triple therapy (p = 0.73) was associated with bleeding. Triple therapy was associated with LVT resolution on meta-analysis (OR 2.53, 95% CI 1.53-4.19, p < 0.001) and regression analysis (OR 1.28, 95% CI 1.03-1.58, p = 0.03). Anticoagulation and triple therapy were independent predictors of systemic embolism ([OR 0.67, 95% CI 0.49-0.93, p = 0.02] and [OR 0.82, 95% CI 0.73-0.93, p = 0.001]) and stroke ([OR 0.62, 95% CI 0.41-0.94, p = 0.03] and [OR 0.73, 95% CI 0.55-0.96, p = 0.03]).

CONCLUSIONS

While there is clear therapeutic benefit in anticoagulation for post-AMI LVT, the extent of bleeding risk is uncertain. Future trials are necessary to determine the optimal antithrombotic strategy for post-AMI LVT management.

Cerebral infarction as initial presentation in stress cardiomyopathy: Case report and literature review

RATIONALE

The typical symptoms of stress cardiomyopathy include sudden-onset chest pain and breathlessness or collapse as well as classical symptoms of cardiovascular disease; however, rare reports have described nervous system symptoms as the initial manifestation. Here, we report the case of a young man who presented with a large cerebral infarction as the main clinical symptom of stress cardiomyopathy to increase recognition of the disease.

PATIENT CONCERNS

A 28-year-old man was admitted to our hospital for sudden-onset weakness of the right limbs and unconsciousness for 1 day. Ten days prior, he began consuming copious amounts of alcohol (500 mL/day) secondary to reactive depression.

DIAGNOSES

Imaging revealed a left internal carotid artery occlusion as assessed by carotid artery ultrasonography. Brain magnetic resonance imaging/magnetic resonance angiography showed new large left cerebral infarction complicated by a reperfusion injury. Moreover, cardiac ultrasonography showed decreased motion of the left ventricular apex, a 3.7 cm mural thrombus in the ventricular apex. The results of coronary and renal artery angiography did not reveal any significant epicardial coronary disease with thrombolysis in the myocardial infarction grade 3 in any of the coronary arteries.

INTERVENTIONS

The patient was administered antiplatelet, anticoagulation, antihypertension, antibiotic, and neurotrophic therapies.

OUTCOMES

The symptoms of cerebral infarction improved significantly after 12 days of admission. Cardiac ultrasonography showed that the wall movement of the left ventricular apex had recovered fully and the mural thrombus resolved completely.

LESSONS

Patients with stress cardiomyopathy exhibit various clinical manifestations and characteristics. On the basis of our in-depth understanding of stress cardiomyopathy, clinicians should diagnose early and develop reasonable and effective therapies to prevent the harmful effects of related complications.

Incidence of Left Ventricular Thrombus in Patients With Acute ST-Segment Elevation Myocardial Infarction Treated with Percutaneous Coronary Intervention

Previous studies using 2-dimensional non-contrast echocardiography have reported a post-ST segment elevation myocardial infarction (STEMI) left ventricular (LV) thrombus incidence of 3% to 24%. However, these studies were not performed with ultrasound contrast agents (UCAs), which improve accuracy in the diagnosis of LV thrombus. We aimed to determine the early incidence and clinical correlates of LV thrombus in a large consecutive cohort of patients with STEMI. This study included consecutive patients admitted to Saint Luke's Mid America Heart Institute with STEMI who also underwent early percutaneous coronary intervention (PCI) and an echocardiogram. A total of 1,698 patients (1,205 men, mean age 61 ± 13 years) comprised the study group. Echocardiography was performed on hospital day 2, and a UCA was used in 1,292 patients (76%). LV thrombus was identified in 28 (1.6%) patients. A multivariable logistic regression model showed that left anterior descending intervention was independently associated with LV thrombus (odds ratio = 7.58, 95% confidence interval [CI] 2.20 to 26.19, p = 0.001), thrombolysis in myocardial infarction III flow was marginally associated with less LV thrombus (odds ratio = 0.41, 95% CI 0.16 to 1.04, p = 0.060), and higher LVEF was associated with less LV thrombus (odds ratio = 0.96, 95% CI 0.91 to 0.97, p <0.001). In conclusion, LV thrombus was identified in only 1.6% of patients in a large STEMI cohort, significantly lower than previous studies. A UCA was used in most echocardiograms, and it improves accuracy in the detection and exclusion of LV thrombus.

Use of Heparin in Acute Ischemic Stroke: Is There Still a Role?

Heparin has long been a contested therapy in acute ischemic stroke (AIS). In current practice, heparin is considered on a case-by-case basis, but there is no consensus as to the appropriate timing of anticoagulation or for which ischemic stroke subtypes heparin may be beneficial. To provide better clarity on this issue, we review current research focusing on the use of heparin in AIS in each stroke subtype and subsequently make recommendations to provide readers with a systematic approach to managing complex stroke patients for which acute anticoagulation may be valuable. We conclude that there are certain subpopulations of ischemic stroke patients that may derive benefit from heparin when given acutely, including patients with symptomatic large artery stenosis >70 %, non-occlusive intraluminal thrombus, and in patients with high-risk cardiac conditions including left ventricular thrombus, left ventricular assist devices, and mechanical heart valves.

Unusual Site of Left Ventricular Thrombus after Acute Myocardial Infarction

Left ventricular (LV) thrombus formation is a frequent complication in patients with acute anterior myocardial infarction (MI). Its incidence is lower with inferior wall MI. Risk factors for the development of LV thrombus are consistently irrespective of infarct treatment and include large infarct size, severe apical akinesia or dyskinesia LV aneurysm, and anterior MI.

Successful medical management of a left ventricular thrombus and aneurysm following failed thrombolysis in myocardial infarction

We report the case of a patient with an extensive anterior myocardial infarction complicated by left ventricular systolic dysfunction, left ventricular apical thrombus and an apical left ventricular aneurysm following failed thrombolysis. We obtained serial two-dimensional echocardiograms at short intervals in the acute phase and also during the months of recovery and follow up. The patient was successfully and exclusively medically managed.

Risk factors for development of left ventricular thrombus after first acute anterior myocardial infarction-association with anticardiolipin antibodies

Background

Left ventricular thrombus(LVT] formation is a frequent complication in patients with acute anterior myocardial infarction(MI). LVT is associated with increased risk of embolism and higher mortality rates after acute MI. Anticardiolipin antibodies (ACA) are immunoglobulins that react with phospholipid-binding proteins interfering with the prothrombin activator complex. The effects of phospholipids on pathophysiology of cardiovascular thrombotic events are well known. In this study, we aimed to evaluate the importance of clinical and biochemical parameters including anticardiolipin antibodies on left ventricular thrombus formation after acute anterior MI.

Methods and Results

Seventy patients with a first anterior AMI were prospectively and consecutively enrolled. Patients with previous MI, autoimmune disease, collagen vascular disease and arterial or venous thrombosis history were excluded from this study. At the time of hospitalization, key demographic and clinical characteristics were collected including age, gender, ethanol intake and presence of traditional risk factors for atherosclerosis (hypertension, diabetes, smoking, hyperlipidemia, positive family history). Patients were evaluated for echocardiographic data, blood chemistry and ACA. Two-dimensional and Doppler echocardiographic examinations were performed in all patients within the first week and at 14 days after MI. LV thrombus was detected in 30 (42.8%) patients. ACA IgM levels were significantly higher in the patient group with LV thrombus than in the group without thrombus (12.44 ±4.12 vs. 7.69 ± 4.25 mpl, p = 0,01). ACA IgG levels were also found higher in the group with LV thrombus (24.2 ± 7.5 vs.17.98 ± 6.45 gpl, p = 0.02). Multivariate analyses revealed diabetes mellitus, higher WMSI, lower MDT and higher ACA IgM and higher ACA IgG levels as independent predictors of left ventricular thrombus formation.

Conclusions

Our data demonstrate that beside the low ejection fraction, lower MDT and higher wall motion score index, modestly elevated ACA IgM and ACA IgG levels are associated with LV thrombus formation in patients with anterior MI.

C-Reactive protein as a risk factor for left ventricular thrombus in patients with acute myocardial infarction

BACKGROUND

Elevated C-reactive protein (CRP) has been found to correlate with higher risk for cardiac events in patients with acute myocardial infarction (AMI). It has been suggested that CRP may be involved in initiation process of coagulation; however, the role of CRP level in the formation of left ventricular (LV) thrombus has not been studied.

HYPOTHESIS

This study investigated whether CRP is a risk factor for LV thrombus in patients with AMI.

METHODS

Clinical, echocardiographic, and biochemical data were analyzed in 141 consecutive patients (aged 57 +/- 13 years; 33 women) with first anterior AMI. Two-dimensional and Doppler echocardiographic examinations were performed on Days 1, 3, 7, 15, and 30. Blood samples were obtained every day during hospitalization. Serum CRP concentrations were measured by an ultrasensitive immunonephelometry method.

RESULTS

Left ventricular thrombus was detected in 33 (23.4%) patients. Univariate analysis showed that patients with LV thrombus had a higher peak creatine kinase (CK) level (2,879 +/- 742 vs. 1,693 +/- 1,210 I/U, p = 0.001), higher peak CRP level (14.9 +/- 7.1 vs. 9.2 +/- 6.8 mg/dl, p = 0.001), higher wall motion score index (1.8 +/- 0.2 vs. 1.5 +/- 0.3, p = 0.002), higher apical wall motion score index (2.35 +/- 0.72 vs. 2.07 +/- 0.70, p = 0.001), larger end-diastolic volume (145.2 +/- 43.7 vs. 116.5 +/- 44.2 ml, p = 0.002), larger end-systolic volume (85.4 +/- 37.2 vs. 62.9 +/- 31.6 ml, p = 0.003), and lower ejection fraction (42.1 +/- 12 vs. 47.3 +/- 13, p = 0.04). In multivariate analyses, only peak CK level (p = 0.0001), LV apical wall motion score index (p = 0.001), and CRP levels (p = 0.001) were independent predictors of LV thrombus formation.

CONCLUSIONS

These results suggest that CRP is a risk factor for LV thrombus in patients with AMI.

Plasma homocysteine level and left ventricular thrombus formation in acute anterior myocardial infarction patients following thrombolytic therapy with t-PA

AIMS

The aim of this study was to evaluate the relationship between homocysteine levels and the development of left ventricular thrombus in acute anterior myocardial infarction patients directed to thrombolytic therapy.

METHODS AND RESULTS

Seventy-nine patients presenting with ST elevated acute anterior myocardial infarction and treated with thrombolytic agent, t-PA, were included in the study. Two-dimensional echocardiography was used to divide patients into 2 groups according to the presence (n = 14) or absence (n = 65) of thrombus in the left ventricle following myocardial infarction. The levels of fasting plasma total homocysteine, total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, vitamin B12 and folic acid were assessed. There were no significant differences between two groups in terms of age, gender, hyperlipidemia and smoking. History of diabetes mellitus (28.57% versus 6.15%, p = 0.04), peak creatine phosphokinase levels (4153.54 +/- 1228.41 U/L versus 2456.92 +/- 1421.36 U/L, p < 0.001), mean left ventricular wall motion score index (2.21 +/- 0.18 versus 1.83 +/- 0.23, p < 0.001) and total fasting homocysteine levels (18.24 +/- 5.67 mmol/L versus 12.31 +/- 3.52 mmol/L, p < 0.001) were significantly higher in patients with left ventricular thrombus. In multivariate analysis; only diabetes mellitus (p = 0.03), higher wall motion score index (p = 0.001) and higher homocysteine levels (p = 0.04) were independent predictors of left ventricular thrombus formation.

CONCLUSION

Our results suggest that; diabetes mellitus, higher wall motion score index and hyperhomocysteinemia independently increases the risk for the development of left ventricular thrombus formation in patients with acute anterior myocardial infarction following thrombolytic therapy.

Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction

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.

Improved detection of left ventricular thrombi and spontaneous echocontrast by tissue harmonic imaging in patients with myocardial infarction

BACKGROUND

Tissue harmonic imaging (THI) reduces near-field and side-lobe artifacts. This could improve recognition of cardiac masses, including thrombi and spontaneous echocontrast (SEC), a known thromboembolic risk factor.

OBJECTIVES

We tested the hypothesis that THI improves detection of left ventricular (LV) thrombi and SEC compared with transthoracic fundamental imaging in patients with recent myocardial infarction.

METHODS

In all, 118 consecutive patients with recent myocardial infarction were studied at predischarge. The echocardiographic examination was performed in both fundamental imaging and THI modality and evaluated by 3 skilled and 3 nonexperienced observers for recognition of LV thrombosis and SEC.

RESULTS

THI increased LV thrombi diagnosis by 25% by skilled observers and by 50% by nonexperienced readers, reducing the number of false-positive diagnoses by 67%. Also, compared with fundamental imaging, THI improved recognition of LV SEC by both experienced and nonexperienced observers by 56% and 62%, respectively.

CONCLUSIONS

The improved recognition of LV thrombosis and SEC by THI in patients with myocardial infarction is clinically relevant allowing appropriate treatment and prognostic stratification. Therefore, routine use of THI should be recommended when studying such patients in clinical practice.

Pulsed wave tissue Doppler-derived myocardial performance index for the assessment of left ventricular thrombus formation risk after acute myocardial infarction

BACKGROUND

Assessment of left ventricular (LV) thrombosis risk after acute myocardial infarction (AMI) is important because of potential embolic sequelae that are reduced by oral anticoagulant agents. The goal of this study was to investigate whether early assessment of LV systolic and diastolic performance with pulsed wave tissue Doppler ultrasound scanning (PWTD) predicts LV thrombosis after AMI.

METHODS

Two-dimensional and Doppler ultrasound scanning echocardiographic examinations were performed in 92 consecutive patients (age, 58 +/- 10 years; 11 women) with first anterior AMI within 24 hours after arrival to the coronary care unit. From the apical 4-chamber view, the mitral annular velocities were recorded at the lateral corner of the mitral annulus with PWTD. The myocardial performance index (MPI), which combines parameters of both systolic and diastolic ventricular function, was calculated from the PWTD recordings. To analyze LV thrombus formation, the 2-dimensional echocardiographic examination was repeated on days 3, 7, 15, and 30. The patients were divided in 2 groups according to LV thrombus formation.

RESULTS

LV thrombus was found in 32 of 92 patients (35%; group 1) and was not found in 60 patients (65%; group 2). The MPI was significantly higher in group 1 than in group 2 (0.73 +/- 0.20 vs 0.53 +/- 0.14; P <.001). When an MPI >0.6 was used as the cutoff, LV thrombus formation could be predicted with a sensitivity rate of 81%, a specificity rate of 73%, a positive predictive value of 62%, and a negative predictive value of 88%. In multivariate analyses, only MPI and LV wall motion score index were independent predictors of LV thrombus formation (P = .038 and P = .047, respectively).

CONCLUSIONS

The MPI derived with PWTD soon after admission appears to be a useful parameter for assessing the risk of LV thrombosis after AMI. Patients with an MPI >0.6 after AMI seem to be at a higher risk for thrombus formation.

[An elderly patients with ventricular aneurysm, thrombus in the aneurysm, and cerebral infarction 10 years after myocardial infarction]

A 75-year-old man had a 26-year history of hypertension and an 18-year history of effort angina pectoris. He suffered acute myocardial infarction at age 61. According to serial echocardiography, the initially hypokinetic segment of the left ventricular apex was transformed to an apical aneurysm over the course of 10 years (at age 71). Ten months later, a transient ischemic attack occurred, despite the administration of aspirin. At age 72, echocardiography revealed a hyperechoic lesion that was suspected to be a thrombus within the aneurysmal cavity. Cerebral infarction (right occipital lobe) occurred 13 years after myocardial infarction, at age 73. After warfarin therapy for 3 months, the thrombus-like echo in the left ventricular aneurysm disappeared.

Relation between early mitral regurgitation and left ventricular thrombus formation after acute myocardial infarction: results of the GISSI-3 echo substudy

OBJECTIVE

To evaluate the prevalence and correlates of left ventricular thrombosis in patients with acute myocardial infarction, and whether the occurrence of early mitral regurgitation has a protective effect against the formation of left ventricular thrombus.

DESIGN AND SETTING

Multicentre clinical trial carried out in 47 Italian coronary care units.

PATIENTS AND METHODS

757 patients from the GISSI-3 echo substudy population with their first acute myocardial infarct were studied by echocardiography at 24-48 hours from symptom onset (S1), at discharge (S2), at six weeks (S3), and at six months (S4). The diagnosis of left ventricular thrombosis was based on the detection of an echo dense mass with defined margins visible throughout the cardiac cycle in at least two orthogonal views.

RESULTS

In 64 patients (8%), left ventricular thrombosis was detected in one or more examinations. Compared with the remaining 693 patients, subjects with left ventricular thrombosis were older (mean (SD) age: 64.6 (13.0) v 59.8 (11.7) years, p < 0.005), and had larger infarcts (extent of wall motion asynergy: 40.9 (11.5)% v 24.9 (14)%, p < 0.001), greater depression of left ventricular ejection fraction at S1 (43.3 (6.9)% v 48.1 (6.8)%, p < 0.001), and greater left ventricular volumes at S1 (end diastolic volume: 87 (22) v 78 (18) ml/m(2), p < 0.001; end systolic volume: 50 (17) v 41 (14) ml/m(2), p < 0.001). The prevalence of moderate to severe mitral regurgitation on colour Doppler at S1 was greater in patients who had left ventricular thrombosis at any time (10.2% v 4.2%, p < 0.05). On stepwise multiple logistic regression analysis the only independent variables related to the presence of left ventricular thrombosis were the extent of wall motion asynergy and anterior site of infarction.

CONCLUSIONS

Left ventricular thrombosis is not reduced, and may even be increased, by early moderate to severe mitral regurgitation after acute myocardial infarction. The only independent determinant of left ventricular thrombosis is the extent of the akinetic-dyskinetic area detected on echocardiography between 24-48 hours from symptom onset.

Role of echocardiography in the assessment of left ventricular thrombus embolic potential after anterior acute myocardial infarction

The contribution of cardiac ultrasound in assessment of the embolic potential of left ventricular thrombi after anterior acute myocardial infarction was verified in a prospective study of serial echocardiograms (mean, 18.9 examinations per patient) obtained over a long-term period (1-72 months; mean, 38±12). The study population comprised 222 patients (162 men; age, 64±11 years) with a first anterior acute myocardial infarction, treated with thrombolysis (group A) or receiving no antithrombolic therapy (group B). Embolism occurred in a total of 12 patients (11 with a left ventricular thrombus; p<0.005) and was more frequent in group B (10 patients; p<0.04). Predictors of embolism were the absence of thrombolysis, detection of a left ventricular thrombus, protrusion or mobility of the thrombus, and morphologic changes in the thrombus over time. Patients in group A had a lower incidence of each of these predictors, and a higher thrombus resolution rate. An appropriate echocardiographic protocol is crucial to assessment of the embolic potential of left ventricular thrombi after anterior acute myocardial infarction and may help to identify candidates for aggressive antithrombotic therapy (c)2001 CHF, Inc.

Doppler-derived mitral deceleration time as an early predictor of left ventricular thrombus after first anterior acute myocardial infarction

BACKGROUND

The relation between left ventricular (LV) diastolic function and LV thrombus has not yet been fully investigated. The aim of this study was to determine whether early assessment of Doppler-derived mitral deceleration time (DT), a measure of LV compliance and filling, may predict LV thrombus formation after acute myocardial infarction.

METHODS AND RESULTS

Two-dimensional and Doppler echocardiographic examinations were performed in 98 consecutive patients (aged 57 +/- 12 years; 8 women) with first acute myocardial infarction. The patients were studied within 24 hours and at days 3, 7, 15, and 30 after arrival to the coronary care unit. Mitral flow velocities were obtained from the apical 4-chamber view with pulsed Doppler. LV thrombus was detected in 20 of 98 patients. Patients were divided into 2 groups according to LV thrombus formation: group 1 (n = 20) with thrombus and group 2 (n = 78) without thrombus. Mitral E-wave DT was significantly shorter in group 1 than group 2 (134 ms vs 175 ms; P <.001). Patients in group 1 had significantly larger LV end-diastolic and end-systolic volumes and a higher wall motion score index than patients in group 2 (133 +/- 39 mL vs 112 +/- 41 mL, P =.03; 83 +/- 34 mL vs 59 +/- 30 mL, P =.003; and 1.8 +/- 0.3 mL vs 1.5 +/- 0.3 mL, P =.007, respectively). The LV ejection fraction was significantly lower in group 1 than in group 2 (39% +/- 13% vs 48% +/- 12%; P =.004). In a multivariate regression analysis, mitral E-wave DT was identified as an independent variable related to development of LV thrombus (P =.04).

CONCLUSIONS

Doppler-derived mitral DT is superior to conventional clinical and 2-dimensional echocardiographic assessment in estimating the risk of left ventricular thrombosis after myocardial infarction.

Prevalence of early left ventricular thrombus after primary coronary intervention for acute myocardial infarction

The prevalence of left ventricular (LV) thrombus after acute myocardial infarction (AMI) has been reported high at 20-60%. Current reperfusion therapies such as thrombolysis have shown a trend toward reducing the incidence of LV thrombosis. However, the prevalence of LV thrombus after primary percutaneous coronary intervention (PCI) for AMI has not been systematically studied. At Massachusetts General Hospital 71 consecutive patients who underwent primary PCI for acute ST elevation MI were reviewed for the prevalence of LV thrombus evaluated by echocardiography. Echocardiography was performed within 5 days of infarction. PCI was successful in all patients. The time delay from symptom onset to intervention was 191 minutes. Thrombolysis in Myocardial Infarction (TIMI) grade 3 flow was achieved in more than 80% of cases. Only 3 patients (4%) had echocardiographic evidence of LV thrombus. All 3 patients had anterior infarctions. The incidence among patients with anterior MI was 10% (3 of 30 patients). The prevalence of LV thrombus in patients treated with primary PCI for AMI is low (4%).

Predictors of left ventricular thrombus formation in patients with anterior myocardial infarction: role of activated protein C resistance

BACKGROUND

Left ventricular mural thrombus formation is a well-recognised consequence of acute anterior myocardial infarction. The vast majority of left ventricular thromboses occur in patients with anterior myocardial infarction and depressed left ventricular function.

OBJECTIVE

To evaluate the factors predicting left ventricular thrombus formation in patients similar for left ventricular function and left ventricular score indexes.

METHODS

We evaluated 45 consecutive patients who met the inclusion criteria of anterior myocardial infarction resulting in apical, anterior or septal asynergy (akinesia, dyskinesia), without non-Q-wave myocardial infarction, dilated cardiomyopathy, or renal or hepatic dysfunction. Patients were divided into two groups: group I with, and group II without, left ventricular mural thrombus. The groups were compared for clinical, echocardiographic and hematologic parameters (activated protein C resistance (APC-R), protein S and antithrombin III).

RESULTS

Smoking and ACP-R were significantly greater in group I than in group II (P < 0.05 and P < 0.005 respectively). Multivariate regression analysis showed that APC-R was an independent risk factor for left ventricular thrombus formation in the patient group selected. Antithrombin III and protein S concentrations were not statistically different between two groups. All other clinical and echocardiographic characteristics of the patients were similar in both groups.

CONCLUSION

APC-R is an independent risk factor for left ventricular thrombosis in patients with anterior myocardial infarction resulting in septal or anterior and apical akinesia or dyskinesia.

Echocardiographic Recognition of Left Ventricular Mural Thrombus

Left ventricular (LV) mural thrombus is a well recognized complication of acute myocardial infarction. In survivors of infarction, its incidence is influenced by the location and magnitude of infarction: it occurs often in patients with large anterior Q wave infarctions, particularly in the presence of LV apical akinesis or dyskinesis. Although radionuclide imaging with indium-111-labeled platelets, computed tomography, and magnetic resonance imaging may be used to identify LV mural thrombus, two-dimensional echocardiography is the technique of choice for assessing its presence, shape, and size, and recent technical advances in echocardiographic methodology, such as high-frequency, short-focal-length transducers, have improved the echocardiographic assessment of LV mural thrombus. In the patient in whom a mural thrombus is identified, acute and chronic anticoagulation (with heparin and warfarin, respectively) is indicated: first, to prevent further thrombus formation and, second, to reduce the incidence of systemic embolization.

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.

Refractory Left Ventricular Failure Due to Large Left Ventricular Thrombus

Mural thrombi are common in patients with acute myocardial infarction and can cause refractory left ventricular failure as a rare complication. We report a case of large postinfarction ventricular thrombus resulting in left ventricular failure resistant to medical therapy. After echocardiographic diagnosis, thrombectomy and coronary bypass grafting were performed and the symptoms subsided.

Predischarge two-dimensional echocardiographic evaluation of left ventricular thrombosis after acute myocardial infarction in the GISSI-3 study

Left ventricular (LV) thrombosis can be found in patients with acute myocardial infarction (AMI). No wide multicenter trial on AMI has provided information about LV thrombosis until now. The protocol of the GISSI-3 study included the search for the presence of LV thrombosis in patients from 200 coronary care units that did not specifically focus on LV thrombosis. We examined the GISSI-3 database results related to 8,326 patients at low to medium risk for LV thrombi in which a predischarge echocardiogram (9 +/- 5 days) was available. LV thrombosis was found in 427 patients (5.1%): 292 of 2,544 patients (11.5%) with anterior AMI and in 135 of 5,782 patients (2.3%) with AMI in other sites (p <0.0001). The incidence of LV thrombosis was higher in patients with ejection fraction < or = 40% (151 of 1,432 [10.5%] vs 276 of 6,894 [4%]; p <0.0001) both in the total population and in the subgroup with anterior AMI (106 of 597 [17.8%] vs 186 of 1,947 [9.6%]; p <0.0001). Multivariate analysis showed that only the Killip class > I and early intravenous beta-blocker administration were independently associated with higher LV thrombosis risk in the subgroup of patients with anterior AMI (odds ratio 1.75, 95% confidence interval 1.28 to 2.39; odds ratio 1.32, 95% confidence interval 1.02 to 1.72, respectively). In patients with anterior AMI, oral beta-blocker therapy given or not given after early intravenous beta-blocker administration does not influence the occurrence of LV thrombosis. The rate of LV thrombosis was similar in patients treated or not treated with nitrates and lisinopril both in the total population and in patients with anterior and nonanterior AMI. In conclusion, in the GISSI-3 population at low to medium risk for LV thrombi, the highest rate of occurrence of LV thrombosis was found among patients with anterior AMI and an ejection fraction < 40%. Killip class > I and the early intravenous beta-blocker administration were the only variables independently associated with a higher predischarge incidence of LV thrombosis after anterior AMI.

Incidence and natural history of left ventricular thrombus following anterior wall acute myocardial infarction

Previous studies have reported left ventricular (LV) thrombus in 20% to 56% of patients after anterior wall acute myocardial infarction (AMI). The Healing and Early Afterload Reducing Therapy (HEART) study was a prospective study comparing effects of early (24 hours) or delayed (14 days) initiation of ramipril, an angiotensin-converting enzyme inhibitor, on LV function after anterior wall AMI. This ancillary study assessed prevalence of LV thrombus. Two-dimensional echocardiography was performed on days 1, 14, and 90 after myocardial infarction. The cohort consisted of 309 patients. Q-wave anterior wall AMI occurred in 78%; 87% received reperfusion therapy. The prevalence of LV thrombus was 2 of 309 (0.6%) at day 1, 11 of 295 (3.7%) at day 14, and 7 of 283 (2.5%) at day 90. One patient had thrombus at 2 examinations. The day 1 echocardiogram was not correlated with thrombus development. LV size increased more in patients with thrombus than in those without thrombus. Patients with thrombus had more wall motion abnormality after day 1 than patients without thrombus (p = 0.03). Thus, the current prevalence of LV thrombus in anterior wall AMI is lower than previously reported, possibly due to changes in AMI management. Preservation of LV function is likely to be an important mechanism. Most thrombi are seen by 2 weeks after AMI. Resolution documented by echocardiography is frequent.

Experience from clinical genetics in hypertrophic cardiomyopathy: proposal for new diagnostic criteria in adult members of affected families

The diagnosis of hypertrophic cardiomyopathy has relied on echocardiographic demonstration of unexplained left ventricular hypertrophy. The prevalence of hypertrophic cardiomyopathy defined in this way has been estimated to be 1:500 and experience indicates that these criteria are relatively specific when other causes of left ventricular hypertrophy are absent. In recent years, however, the systematic evaluation of pedigrees performed in the context of molecular genetic studies revealed that in some families with hypertrophic cardiomyopathy up to 20% of adults who carry a disease causing gene defect do not fulfil conventional echocardiographic criteria. None the less, most of these individuals show symptoms, electrocardiographic alterations, and/or minor echocardiographic abnormalities. Revised diagnostic criteria in members of families with hypertrophic cardiomyopathy are proposed, including major and minor criteria based on symptoms, and electrocardiographic and echocardiographic abnormalities. Given that the chance of inheriting the gene defect is 1:2, the likelihood that symptoms plus electrocardiographic or echocardiographic abnormalities are the expression of a disease causing gene is high.

Long term follow up of patients with anterior myocardial infarction complicated by left ventricular thrombus in the thrombolytic era

OBJECTIVES

To examine the appearance and resolution of left ventricular thrombi and to study the relation between thrombus and mortality during long term follow up after anterior myocardial infarction.

DESIGN

Ninety nine consecutive patients were prospectively studied until the last included patient had been followed for one year. Streptokinase and aspirin were used routinely, anticoagulants only after a decision by the attending physician. Echocardiography was performed within 3 d of admission, before discharge, and after one, three, and 12 months.

SETTING

Umeå University Hospital, a teaching hospital in Northern Sweden.

MAIN OUTCOME MEASURES

Left ventricular thrombus, segmental myocardial function, and mortality during follow up.

RESULTS

Thirty patients (30%) had a thrombus on discharge. One month, three months, and 12 months after hospital discharge, the thrombus had resolved in 81%, 84%, and 90% of the patients, respectively. The proportion of resolved thrombi at one month was high irrespective of whether anticoagulants were given (10/11, 91%) or not (12/16, 75%), P = 0.4. New thrombi appeared in 12 patients after discharge and resolution and reapperance of thrombi continued during the follow up period. Patients who developed a thrombus during the hospital stay (n = 44, 44%) had more extensive myocardial dysfunction on discharge (P < 0.001) and significantly higher mortality during the follow up period than those without a thrombus (23% v 7%, P < 0.01).

CONCLUSIONS

With routine thrombolytic and aspirin treatment of anterior myocardial infarction, left ventricular thrombi usually resolve during the first month after hospital discharge. Appearance and resolution of thrombi continue, however, in a significant proportion of the patients during long term follow up. A left ventricular thrombus during the initial hospital stay is associated with high long term mortality.

Left ventricular thrombosis after anterior myocardial infarction with and without thrombolytic treatment

OBJECTIVES

To examine the incidence of left ventricular thrombus in patients with anterior myocardial infarction, with and without streptokinase treatment. To identify predictors of thrombus development.

DESIGN

Consecutive patients prospectively studied during the hospitalized period. Echocardiography was performed within 3 days of admission and before discharge.

SETTING

Umeå University Hospital, a teaching hospital in Northern Sweden.

SUBJECTS

Ninety-nine patients with anterior myocardial infarction of whom 74 were treated with streptokinase.

MAIN OUTCOME MEASURES

Left ventricular thrombus and left ventricular segmental myocardial function.

RESULTS

During the hospital stay, a thrombus developed in 46% (95% confidence interval [CI], 35-57%) of the patients in the thrombolysis group and in 40% (95% CI, 21-59%) of the patients in the non-thrombolysis group. No difference in left ventricular segmental myocardial function was found between the thrombolysis and non-thrombolysis groups at hospital discharge. No embolic events were observed. The occurrence of a left ventricular thrombus at hospital discharge was significantly associated with previous myocardial infarction, peak enzyme levels, left ventricular global and segmental dysfunction and an increased dose of peroral diuretics or use of parenteral diuretics. In a multiple logistic regression model, left ventricular segmental dysfunction was the most important predictor of left ventricular thrombus.

CONCLUSION

Thrombolytic treatment with streptokinase does not prevent the development of a left ventricular thrombus but the risk of embolic complications is low. The left ventricular segmental myocardial score can be used to assess the risk of thrombus development, also, after thrombolysis.

Doppler left ventricular flow pattern versus conventional predictors of left ventricular thrombus after acute myocardial infarction

OBJECTIVES

The value of Doppler-derived left ventricular spatial flow patterns in predicting left ventricular thrombus formation after myocardial infarction was compared with that of conventional clinical and echocardiographic variables.

BACKGROUND

Assessment of left ventricular thrombosis risk after myocardial infarction is important because of potential embolic sequelae that are reduced by oral anticoagulant agents.

METHODS

Clinical, two-dimensional and Doppler echocardiographic data were prospectively obtained in 104 patients with acute myocardial infarction within 48 h of admission. Ventricular flow was assessed by Doppler echocardiography and considered normal when brisk ventricular inflow with simultaneous onset at the mitral valve and apical levels was present, together with alternating directions of apical flow throughout the cardiac cycle. In addition to normal flow, two abnormal flow patterns were recognized: apical rotating flow and vortex ring formation. Oral anticoagulant agents were prescribed only to patients with abnormal flow at admission. The incidence of left ventricular thrombosis was assessed by echocardiography during 9 months of follow-up.

RESULTS

Abnormal flow pattern had a positive predictive value of 63% and a negative predictive value of 99%. On stepwise logistic regression analysis, only abnormal flow pattern had an independent relation to left ventricular thrombus (odds ratio 92).

CONCLUSIONS

Left ventricular flow pattern derived by Doppler echocardiography soon after admission is superior to conventional clinical and two-dimensional echocardiographic assessment in estimating the risk of left ventricular thrombosis after myocardial infarction.

Risk of arterial embolization in 224 patients awaiting cardiac transplantation

Of patients awaiting cardiac transplantation, 10% to 20% die before a donor heart becomes available. Embolization of left ventricular thrombus is a source of morbidity and mortality in this population. To define the incidence and possible risk factors for systemic arterial embolization, we examined the frequency of arterial embolic events and their relation to clinical, hemodynamic, and echocardiographic variables in 224 consecutive outpatients awaiting cardiac transplantation (left ventricular ejection fraction 0.20 +/- 0.07 and left ventricular end-diastolic dimension 76 +/- 11 mm). Over a follow-up period of 301 +/- 371 days, during which 82 (37%) patients received warfarin, arterial embolization occurred in 6 (3%) patients, 1 of whom was receiving and 5 of whom were not receiving warfarin (difference not specifically significant). The risk of embolization was not statistically different in patients with atrial fibrillation, previous embolization, or left ventricular thrombus on transthoracic echocardiogram, regardless of warfarin therapy. Cumulative risk of sudden death was similar for patients with or without echocardiographically documented left ventricular thrombus. Nonfatal bleeding complications associated with warfarin therapy occurred in 2 (2%) patients. Thus in patients who are awaiting cardiac transplantation and who receive anticoagulation therapy for left ventricular thrombus, atrial fibrillation, or previous arterial embolization, the incidence of clinically detectable arterial embolization is low despite severe ventricular dilatation. Embolization is not likely a major cause of sudden death or morbidity in this population.

Efficacy of high dose intravenous heparin for treatment of left ventricular thrombi with high embolic risk

OBJECTIVES

This study was performed to assess the efficacy of high dose intravenous heparin to treat mobile or protruding left ventricular thrombi as detected by serial echocardiography.

BACKGROUND

The presence of mobile and protruding left ventricular thrombi greatly increases the risk of arterial embolization, yet optimal therapy, be it thrombolysis, anticoagulation or surgical removal, has not been defined.

METHODS

Full dose heparin, 31,291 +/- 7,980 (mean +/- SD) IU/day, to prolong partial thromboplastin time to at least twice normal, was administered intravenously to 23 consecutive patients with 25 mobile and protruding thrombi. Patients were prospectively evaluated for hemorrhagic complications and embolic events during therapy. The presence or absence of thrombi and their size and characteristics were assessed by serial echocardiography.

RESULTS

In all 23 patients left ventricular thrombi decreased in size, with disappearance of the high risk features. The duration of high dose heparin infusion was 7 to 22 days (mean 14 +/- 4). Thrombus size was reduced from 3.9 +/- 2.6 to 0.16 +/- 0.38 cm2, and thrombus disappeared entirely in 19 (83%) of 23 patients. No embolic events were detected during treatment, and the only complication was an upper gastrointestinal hemorrhage that was successfully treated medically.

CONCLUSION

High dose intravenous heparin is a highly effective and safe treatment for completely resolving left ventricular thrombi with high risk features for embolization. Most such thrombi disappear completely within 1 to 3 weeks of this treatment without embolic or hemorrhagic complications.