From swirling to a mobile, pedunculated mass--the evolution of left ventricular thrombus despite full anticoagulation. Echocardiographic demonstration

Left ventricle pedunculated thrombi risks and outcomes: a case report and literature review

A 42-year-old male with ischemic cardiomyopathy presented with acute bilateral femoral artery embolization. After management with embolectomy and fasciotomy in both femoral arteries, transthoracic echocardiography revealed two pedunculated highly mobile left ventricle (LV) thrombi. Given the procedural risk, anticoagulation therapy was recommended over surgery. However, the bleeding risk impeded the continuation of anticoagulation, which increased the thrombus size. Multiorgan failure and disseminated intravascular coagulopathy followed and the patient died. We also systematically reviewed the PubMed and Scopus databases for pedunculated LV thrombi cases and retrieved 74 and 63 reports respectively. Of these, 37 relevant reports (45 cases) plus 11 reports from the manual search were included for data extraction, a total of 56 cases besides our case. Based on the etiologies and risks, LV thrombi are predictable and preventable, especially after ischemic events. A clear diagnostic algorithm and vigilant follow-up are needed as well as multidisciplinary management once a diagnosis is confirmed.

Surgical Transmitral Thrombectomy to Prevent Recurrent Stroke in Acute Myocardial Infarction

Left ventricular (LV)-thrombi occur in up to 14 % of patients with acute myocardial infarction (AMI) in the era of primary percutaneous coronary intervention. For these patients, anticoagulant therapy (AC) is recommended by AMI-guidelines. When, despite AC, LV-thrombi lead to embolism, surgical thrombectomy is an option, which is not mentioned or not recommended in AMI-guidelines. We report a 46-year old female patient with AMI. An 80 % stenosis of the proximal left anterior descending coronary artery was treated by a drug-eluting stent. Thrombi within the akinetic LV-apex became mobile despite AC and dual antiplatelet therapy, and a cerebellar stroke occurred. By a transmitral surgical approach with endoscopic assistance the thrombi were completely removed. Postoperative course and 12-months follow-up were uneventful. LV-thrombi should be observed carefully regarding changes in morphology. Surgical thrombectomy of LV-thrombi is a rare treatment option to prevent imminent embolism. Benefits versus risks of surgical removal of LV-thrombi need to be carefully weighted.

Acute myocardial infarction not attributed to coronary artery disease: A seldom initial presentation of a left ventricular myxoma

Although myxoma represents the most frequent non-malignant cardiac primary tumor; it is extremely rare met in the left ventricle. Clinical features of the neoplasm extend from symptomless to critical signs of either ischemia or embolism. We describe here an unusual case of a huge left ventricular myxoma in a 68-year-old man, presented with clinical and ECG findings of an inferior wall myocardial infarction. The patient was primarily referred to our institution for coronary angiography, which showed no coronary artery disease. Further examinations revealed a left ventricular mass as the possible source of embolization, thus the patient underwent surgery for tumor excision. The postoperative course was unremarkable. A bibliographical analysis demonstrated that those tumors are rare but treatable causes of embolic myocardial infarction, thus profound clinical intuition, proper utilization of imaging modalities, administration of anticoagulants preoperatively, as well immediate surgical removal are justified.

Left ventricular mass: myxoma or thrombus?

Patient with embolic episode should always be evaluated for cardiac mass. Mass in left ventricular can be a myxoma or thrombus even in a normal functioning heart. In either case, mobile mass with embolic potential should be surgically resected.

Mobile pedunculated left ventricular masses in a man with recurrent emboli

A 51-year-old man was found to have left ventricular masses by transthoracic echocardiography, one attached to the posterior wall of the left ventricle and another attached to the anterolateral wall of the left ventricle. He had several events of systemic embolization over the last few weeks. Surgical excision was recommended to avoid further embolization. The patient underwent successful resection of the left ventricular masses under cardiopulmonary bypass through the left atrial and transverse aortotomy approach. Histopathologic exam was diagnostic for organized thrombi.

Improved Detection of Spontaneous Echo Contrast in the Aorta with Tissue Doppler Imaging

AIMS

Spontaneous echo contrast (SEC) within the cardiac chambers has been associated with increased risk of thromboembolism. We investigated the presence and severity of SEC in the aorta with tissue Doppler imaging (TDI) and compared these to the aortic flow velocity and to the clinical profile of the patients.

METHODS AND RESULTS

Seventy patients (35 males, 35 females, mean age 64, 22-86 years) underwent TEE for standard indications. Spontaneous echo contrast was studied with conventional and TDI imaging. Aortic flow velocity was measured in the center and lateral part of the descending aorta. SEC of any grade was detected in 24 patients with conventional imaging and in 53 using TDI (P < 0.0001). The presence of swirling was associated with aortic atherosclerosis, older age, history of hypertension and coronary artery disease, atrial fibrillation, and previous embolic events. There was correlation between intraaortic swirling, larger descending aortic diameter (23.6 vs 17 mm, P < 0.00001) and lower peak aortic flow velocity (55 vs 68 cm/s, P = 0.038).

CONCLUSION

Spontaneous echo contrast in the aorta is common in high-risk patients and is associated with increased clinical profile, larger aortic diameter, and lower peak aortic flow velocity. Tissue Doppler imaging is more sensitive in the detection of SEC than conventional imaging.

Power Doppler-derived speckle tracking image of intraventricular flow in patients with anterior myocardial infarction: correlation with left ventricular thrombosis

The abnormal spatial distribution of intraventricular flow is superior to clinical and two-dimensional (2-D) echocardiographic variables in predicting left ventricular thrombosis after myocardial infarction. Echocardiography was prospectively performed in 79 patients within 72 h after anterior wall myocardial infarction onset and repeated before discharge. The apical rotating flow pattern in color flow map was recognized as abnormal. By power Doppler echocardiography, the moving blood could generate speckle tracking images to delineate the intraventricular flow. A swirling flow pattern indicating the compartmentalization of left ventricular blood flow with some blood stagnant in the apical dyssynergic area was identified. The flow pattern shown by the speckle tracking image was superior to the color-flow map in correlating with left ventricular thrombosis. It implicated that the more the detail in which we can describe the blood flow pathway, the more information we can realize.

The role of echocardiography in assessing the morphological response of left ventricular thrombus to anticoagulation

We present a patient with idiopathic dilated cardiomyopathy and a large left ventricular apical thrombus in which serial echocardiography over a 1-month period documented progressive enlargement of this mural thrombus. This case illustrates the dramatic progression of left ventricular thrombus size despite aggressive anticoagulation. In addition, the critical role of echocardiography in the diagnosis and follow-up of patients with left ventricular thrombus is emphasized.