VENTRICULAR THROMBUS

Mark Tuttle, 2013

EPIDEMIOLOGY​1 ● Following MI: 4% in PCI era, up to 20% in pre-PCI era ● End-stage cardiomyopathy: 11-44% prevalence    DIAGNOSIS​1  ● MRI with contrast: 88% sensitive, 99% specific ● Transthoracic echocardiogram: 23% sensitive, 96% specific ● Transesophageal echocardiogram: 40% sensitive, 96% specific RISK OF FACTORS ● Case-control study​2​ of 144 patients being evaluate for heart transplant, 28 with LV thrombus, 116 without ○ Mean follow-up: 27.6 months ○ Risk factors identified for thrombus and subsequent thromboembolism ■ Left ventricular internal diastolic dimension (LVIDD) > 60 mm ■ Lower EF ■ Apical aneurysm ■ Ischemic etiology of heart failure ● High risk features​3​: recent MI, recent systemic embolus, and thrombus protrusion or mobility. ● Low-risk features​3​: remote MI, absence of systemic embolus, mural or sessile thrombus without mobility ● Very low-risk features​3​: Mural thrombus without protrusion or mobility within aneurysm MANAGEMENT​3​: ​Goal is to prevent systemic embolization ● Anticoagulation​: For high-risk features, low-risk features. Can avoid if very low-risk features. ○ Re-image in 3 months ● Thrombolytics​: May increase risk of embolic events and is not recommended. ● Surgical embolectomy​: Should be reserved for recurrent embolic events when accompanied by other indicated cardiac surgery. SOURCES  1. Leick J, Szardien S, Liebetrau C, et al. Mobile left ventricular thrombus in left ventricular dysfunction: case report and review of literature. Clinical research in cardiology : official journal of the German Cardiac Society 2013;102:479-84. 2. Sharma ND, McCullough PA, Philbin EF, Weaver WD. Left ventricular thrombus and subsequent thromboembolism in patients with severe systolic dysfunction. Chest 2000;117:314-20. 3. Stokman PJ, Nandra CS, Asinger RW. Left Ventricular Thrombus. Current treatment options in cardiovascular medicine 2001;3:515-21.