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      Challenges in management of left ventricular thrombus

      Author(s): 1 , 2
      Publication date Created:
      Publication date (Electronic):
      Journal: Therapeutic Advances in Cardiovascular Disease
      Publisher: SAGE Publications

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          Abstract

          <p class="first" id="d13874521e114">Left ventricular thrombus (LVT) complicates both ischemic and non-ischemic cardiomyopathies and is a potential cause of thromboembolic complications such as stroke. Management of LVT in the 21st century is primarily based on studies before the widespread use of potent pharmacological and interventional therapies such as primary percutaneous coronary intervention, especially in the setting of acute myocardial infarction. Though advances in diagnostic technology have improved detection of LVT, clinicians face several uncertainties in the management of LVT in daily practice. The aim of this paper is to examine several controversies in the diagnosis and management of LVT. Prospective studies are needed to advance therapy of LVT. </p>

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          2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines.

          Patrick O'Gara, Frederick Kushner, Deborah D Ascheim … (2013)
          Article 0 comments Cited 862 times – based on 0 reviews     Review now
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            Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction.

            Jonathan Weinsaft, R. Patel, T. J. Kim … (2008)
            This study sought to assess the prevalence and markers of left ventricular (LV) thrombus among patients with systolic dysfunction. 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. 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. 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. 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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              Visualization of ventricular thrombi with contrast-enhanced magnetic resonance imaging in patients with ischemic heart disease.

              Nico Mollet, Steven Dymarkowski, Lieven Herbots … (2002)
              Ventricular thrombus formation is a frequent and potentially dangerous complication in patients with ischemic heart disease. Although transthoracic echocardiography (TTE) is generally used as diagnostic technique, we explored the role of contrast-enhanced (CE)-MRI to detect ventricular thrombi. In 57 patients with acute myocardial infarction, chronic myocardial infarction, or ischemic cardiomyopathy, MRI was performed to evaluate ventricular function (CINE-MRI) and to depict presence of myocardial necrosis and/or scarring and no-reflow areas (CE-MRI). All studies were analyzed for concomitant ventricular thrombi. CE-MRI depicted 12 mural thrombi (3.1+/-2.9 cm3), located in left ventricular (LV) apex or adherent to anteroseptum, presenting as black, well-defined structures surrounded by bright contrast-enhanced blood. Thrombus formation on CE-MRI was related to larger end-diastolic volumes; lower ejection fractions; the region of delayed enhancement and lowest wall motion score, especially in left anterior descending coronary artery territory; and LV aneurysm formation. On CINE-MRI, thrombi were found in 6 patients. Nonvisualized thrombi were usually small (mean size 1.2+/-0.7 cm3). TTE depicted thrombi in 5. Nonvisualized lesions were most frequently located in LV apex and had a larger size than nonvisualized lesions on CINE-MRI (3.0+/-3.2 cm3). In 3 patients with suspected apical thrombus on TTE, MRI was normal. CE-MRI is not only an excellent technique to depict myocardial necrosis and scar tissue in patients with ischemic heart disease, but this study also suggests a better identification of LV thrombi than with presently used clinical imaging modalities, such as TTE.
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                Author and article information

                Journal
                Title: Therapeutic Advances in Cardiovascular Disease
                Abbreviated Title: Therapeutic Advances in Cardiovascular Disease
                Publisher: SAGE Publications
                ISSN (Print): 1753-9447
                ISSN (Electronic): 1753-9455
                Publication date Created: June 07 2017
                Publication date Created: August 2017
                Publication date (Electronic): June 07 2017
                Publication date (Print): August 2017
                Volume: 11
                Issue: 8
                Pages: 203-213
                Affiliations
                [1 ]Department of Medicine, University of Arkansas for Medical Sciences, Little Rock, AR, USA
                [2 ]Division of Cardiology, University of Arkansas for Medical Sciences, 4301 West Markham Street, slot 532, Little Rock, AR 72205, USA
                Article
                DOI: 10.1177/1753944717711139
                PMC ID: 5933579
                PubMed ID: 28589748
                SO-VID: aeecf603-5032-45bb-99a1-cad46582eb97
                Copyright © © 2017
                License:

                http://journals.sagepub.com/page/policies/text-and-data-mining-license

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