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Leow AST, Goh FQ, Tan BYQ, Ho JSY, Kong WKF, Foo RSY, Chan MYY, Yeo LLL, Chai P, Geru A, Yeo TC, Chan SP, Zhou X, Lip GYH, Sia CH. Clinical phenotypes and outcomes of patients with left ventricular thrombus: an unsupervised cluster analysis. Hellenic J Cardiol 2025; 81:65-74. [PMID: 39208930 DOI: 10.1016/j.hjc.2024.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2024] [Revised: 08/12/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Left ventricular thrombus (LVT) can develop in a diverse group of patients with various underlying causes, resulting in divergent natural histories and trajectories with treatment. Our aim was to use cluster analysis to identify unique clinical profiles among patients with LVT and then compare their clinical characteristics, treatment strategies, and outcomes. METHODS We conducted a retrospective study involving 472 patients with LVT whose data were extracted from a tertiary center's echocardiography database, from March 2011 to January 2021. We used the TwoStep cluster analysis method, examining 19 variables. RESULTS Our analysis of the 472 patients with LVT revealed two distinct patient clusters. Cluster 1, comprising 247 individuals (52.3%), was characterized by younger patients with a lower incidence of traditional cardiovascular risk factors and relatively fewer comorbidities compared with Cluster 2. Most patients had LVT attributed to an underlying ischemic condition, with a larger proportion being due to post-acute myocardial infarction in Cluster 1 (68.8%), and due to ischemic cardiomyopathy in Cluster 2 (57.8%). Notably, patients in Cluster 2 exhibited a reduced likelihood of LVT resolution (hazard ratio [HR] 0.58, 95% confidence interval [CI] 0.44-0.77, p < 0.001) and a higher risk of all-cause mortality (HR 2.27, 95% CI 1.43-3.60, p = 0.001). These associations persisted even after adjusting for variables such as anticoagulation treatment, the presence of left ventricular aneurysms, and specific LVT characteristics such as mobility, protrusion, and size. CONCLUSION Through TwoStep cluster analysis, we identified two distinct clinical phenotypes among patients with LVT, each distinguished by unique baseline clinical attributes and varying prognoses.
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Affiliation(s)
- Aloysius S T Leow
- Department of Medicine, National University Health System, Singapore
| | - Fang Qin Goh
- Department of Medicine, National University Health System, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Jamie S Y Ho
- Department of Medicine, National University Health System, Singapore
| | - William K F Kong
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Roger S Y Foo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Cardiovascular Metabolic Disease Translational Research Programme, National University of Singapore, Singapore
| | - Mark Y Y Chan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Ping Chai
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - A Geru
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Tiong-Cheng Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore
| | - Siew Pang Chan
- Centre for Behavioural and Implementation Science Interventions, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Xin Zhou
- Department of Cardiology, Tianjin Medical University General Hospital, Tianjin, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, United Kingdom; Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Cardiology, National University Heart Centre, Singapore.
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Newman E. Acute aortic occlusion: A point-of-care ultrasound case report. Australas J Ultrasound Med 2024; 27:254-258. [PMID: 39734618 PMCID: PMC11671735 DOI: 10.1002/ajum.12404] [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: 12/31/2024] Open
Abstract
Introduction Acute aortic occlusion (AAO) is a rare vascular emergency with significant associated morbidity and mortality. Methods This case report discusses a 39-year-old gentleman with methamphetamine-associated cardiomyopathy (MACM) who presented with bilateral lower limb ischaemia. A POCUS was performed to rapidly evaluate the patient on arrival, which demonstrated AAO. A literature review was conducted to identify similar cases where AAO was detected by POCUS. Results POCUS showed a left ventricular thrombus (LVT), an embolus in the distal abdominal aorta and no flow distal to the embolus, which is consistent with AAO. The patient was successfully reperfused and had a good outcome after a timely diagnosis and management. Discussion This case report outlines a rare pathology in an uncommon age group where POCUS can expedite diagnosis and management. Conclusion POCUS is a valuable tool, which can expedite and facilitate rapid revascularisation of AAO.
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Affiliation(s)
- Erin Newman
- Shellharbour HospitalMount WarrigalNew South WalesAustralia
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Wang Q, Wang B, Zhang X, Zhong X, Chang S, Yang J, Liang J, You Q, Zhou H, Zhang J. The usefulness of contrast echocardiography in the evaluation of cardiac masses: a multicenter study. BMC Cardiovasc Disord 2024; 24:43. [PMID: 38218809 PMCID: PMC10787966 DOI: 10.1186/s12872-024-03708-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 01/03/2024] [Indexed: 01/15/2024] Open
Abstract
BACKGROUND Cardiac masses can encompass a variety of conditions, such as tumors, thrombi, vegetations, calcific lesions, and other rare diseases. Treatment and management of these types of cardiac masses differ considerably. Thus, accurately distinguishing among thrombi, benign tumors, and malignant tumors in the heart is of great importance. Contrast echocardiography (CE) has emerged as a promising technology. Although published guidelines suggest that CE can enhance image quality and assist in differentiating between benign and malignant lesions, most studies on CE diagnosis of cardiac masses are limited to case reports or retrospective/small-sample-sized prospective cohorts. This study aims to evaluate the diagnostic accuracy of CE in patients with suspected cardiac masses and address the insufficient evidence for differential diagnosis using CE. METHODS Between April 2018 and July 2022, a prospective multicenter study was conducted, which included 145 consecutive patients suspected to have cardiac masses based on transthoracic echocardiography. All patients underwent CE examinations. The echocardiographic diagnosis relied on qualitative factors such as echogenicity, boundary, morphology of the base, mass perfusion, pericardial effusion, and motility as well as quantitative factors such as the area of the masses and the peak intensity ratio of the masses to adjacent myocardium (A1/A2). RESULTS The final confirmed diagnoses were as follows: 2 patients had no cardiac mass, 4 patients had pseudomass, 43 patients had thrombus, 66 patients had benign tumors, and 30 patients had malignant tumors. The receiver operating characteristic (ROC) analysis indicated that an optimal A1/A2 cutoff value of 0.499 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.977, 97.9%, 90.7%, 95.9%, and 95.1%, respectively. The optimal A1/A2 cutoff value of 1.583 distinguished a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.950, 93.3%, 93.9%, 87.5%, and 96.9%, respectively. CONCLUSIONS Combined with qualitative and quantitative analyses, CE has the potential to accurately differentiate among different types of cardiac masses.
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Affiliation(s)
- Qingtao Wang
- Department of Cardio-Thoracic Surgery, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, No 15, Jiefang Avenue, Xiangyang, 441000, China
| | - Bing Wang
- Department of Cardio-Thoracic Surgery, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, No 15, Jiefang Avenue, Xiangyang, 441000, China
| | - Xiaofeng Zhang
- Department of Ultrasound, First Affiliated Hospital of Guangxi Medical University, Nanning, 530021, China
| | - Xin Zhong
- Department of Ultrasound, Hunan Provincial People's Hospital, The First Affiliated Hospital of Hunan Normal University, Changsha, 410002, China
| | - Shuai Chang
- Department of Ultrasound, First Affiliated Hospital of University of South China, Hengyang, 421001, China
| | - Jinbo Yang
- Department of Cardio-Thoracic Surgery, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, No 15, Jiefang Avenue, Xiangyang, 441000, China
| | - Jian Liang
- Department of Cardio-Thoracic Surgery, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, No 15, Jiefang Avenue, Xiangyang, 441000, China
| | - Qiangqiang You
- Department of Cardio-Thoracic Surgery, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, No 15, Jiefang Avenue, Xiangyang, 441000, China
| | - Heng Zhou
- Department of Cardio-Thoracic Surgery, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, No 15, Jiefang Avenue, Xiangyang, 441000, China.
| | - Jiaqi Zhang
- Department of Ultrasound, Xiangyang No. 1 People's Hospital, Hubei University of Medicine, No 15, Jiefang Avenue, Xiangyang, 441000, China.
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Kurt D, Yılmaz E, Çamcı S, Aydın E, Çelik Ş. Incidence and Predictors of Left Ventricular Thrombus Formation After Acute Myocardial Infarction With ST-Segment Elevation. Cureus 2023; 15:e50495. [PMID: 38222227 PMCID: PMC10787315 DOI: 10.7759/cureus.50495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2023] [Indexed: 01/16/2024] Open
Abstract
Background and objective Our prospective study aimed to evaluate the frequency and risk factors of left ventricular thrombus (LVT) occurring after acute ST-segment elevation myocardial infarction (STEMI) in the era of primary percutaneous coronary intervention (PCI). Methods Our study included 131 patients diagnosed with acute STEMI who were followed up and treated. The presence of the thrombus was determined by transthoracic echocardiography (TTE). Study patients were evaluated as cases of thrombus (+) and thrombus (-). The relationship of electrocardiographic measurements such as the number of leads with pathological Q waves, ST segment deviation score, QT dispersion, and echocardiographic measurements such as ejection fraction (EF), end-systolic and end-diastolic volumes, and wall motion score index (WMSI) with LVT was investigated. LVT risk factors were identified. Results The median age of the study patients was 59.7 ± 11.7 years, and 84.7% were male. The incidence of LVT was 17.6% (23 patients). While the anterior STEMI rate was 86.9% in the thrombus (+) group, it was 50.9% in the thrombus (-) group (p<0.001). While WMSI was 2.1 ± 0.44 in the thrombus (+) group, it was calculated as 1.40 ± 0.31 in the thrombus (-) group (p<0.001). In the thrombus (+) group, EF was found to be lower, end-systolic and end-diastolic volumes were higher, and the rate of moderate and severe mitral regurgitation and the rate of aneurysmatic segment detection were higher. LVT had a moderate correlation with WMSI (r: 0.613; p<0.001), the presence of an aneurysmatic segment (r: 0.549; p<0.001), and EF (r: -0.514; p<0.001). Presentation with anterior STEMI (odds ratio [OR]: 4.266; p<0.001), WMSI (OR: 7.971; p=0.012), the number of leads with pathological Q waves detected at discharge (OR: 3.651; p=0.009), the presence of an aneurysmatic segment (OR: 2.089, p=0.009), and EF (OR: 1.129, p=0.006) were identified as independent risk factors of the presence of LVT. The area under the curve for WMSI was found to be 0.910 (95% CI: 0.852-0.968). A WMSI cut-off of 1.56 identified LVT with 91% sensitivity and 70% specificity (Youden index: 0.617). Conclusion In the primary PCI era, LVT incidence after acute STEMI is still significant. Anterior STEMI, the number of leads with pathological Q waves detected at discharge, WMSI, aneurysm formation, and low EF are independent risk factors for LVT. Among these risk factors, the variable with the highest diagnostic power is WMSI.
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Affiliation(s)
- Devrim Kurt
- Cardiology, Giresun University Faculty of Medicine, Giresun, TUR
| | - Emre Yılmaz
- Cardiology, Giresun University Faculty of Medicine, Giresun, TUR
| | - Sencer Çamcı
- Cardiology, Bursa Postgraduate Hospital, Bursa, TUR
| | - Ertan Aydın
- Cardiology, Giresun University Faculty of Medicine, Giresun, TUR
| | - Şükrü Çelik
- Cardiology, Trabzon Ahi Evran Thoracic and Cardiovascular Surgery Training and Research Hospital, Trabzon, TUR
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Bayam E, Çakmak EÖ, Yıldırım E, Kalçık M, Bilen Y, Güner A, Küp A, Kahyaoğlu M, Çelik M, Öcal L, Avcı A, Zehir R. The relationship between CHA2DS2VASc score and left ventricular apical thrombus formation in patients with acute anterior ST segment elevation myocardial infarction. Acta Cardiol 2023; 78:24-31. [PMID: 34714216 DOI: 10.1080/00015385.2021.1991667] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
BACKGROUND Left ventricular apical thrombus (LVAT) formation is a well-known complication of acute anterior myocardial infarction (AMI). The CHA2DS2VASc is a scoring system that has been used to estimate the risk of thromboembolism in patients with nonvalvular atrial fibrillation. This score has also been used for other clinical conditions. The aim of this study was to investigate the relationship between CHA2DS2VASc score and development of LVAT in patients with AMI. METHOD The study population included 378 patients (mean age: 56.5 ± 12.3 years, male: 318) presenting with AMI between January 2016 and January 2020. Primary percutaneous coronary intervention procedure was performed in all patients. Initial echocardiogram was performed within 7 days of admission. All patients were evaluated with echocardiography at 3rd, 6th and 12th months. Patients were divided into two groups according to the presence of LVAT on echocardiography. RESULTS The incidence of the LVAT was 8.5% (n = 32) during a mean follow-up time of 233.1 ± 66.7 days. The mean CHA2DS2VASc score was notably higher in patients with LVAT compared to patients in the control group (3.1 ± 1.9 vs. 1.9 ± 1.2, p < 0.001). In Cox regression analysis, high CHA2DS2VASc score, low left ventricular ejection fraction (LVEF) and the presence of LV apical akinesis/aneurysm were the independent predictors for LVAT formation. All of these parameters were associated with higher cumulative incidence of LVAT formation in Kaplan-Meier analyses (p < 0.001 for all). CONCLUSION High CHA2DS2VASc score, low LVEF and the presence of LV apical akinesis/aneurysm may be used for LVAT risk prediction among patients presenting with AMI.
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Affiliation(s)
- Emrah Bayam
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Ender Özgün Çakmak
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Ersin Yıldırım
- Depertament of Cardiology, University of Medical Sciences, Umraniye Training and Research Hospital, İstanbul, Turkey
| | - Macit Kalçık
- Depertament of Cardiology, Hitit University, Faculty of Medicine, Çorum, Turkey
| | - Yusuf Bilen
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Ahmet Güner
- Department of Cardiology, Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Istanbul, Turkey
| | - Ayhan Küp
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Muzaffer Kahyaoğlu
- Department of Cardiology, Abdülkadir Yüksel State Hospital, Gaziantep, Turkey
| | - Mehmet Çelik
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Lütfi Öcal
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Anıl Avcı
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
| | - Regayip Zehir
- Depertament of Cardiology, University of Medical Sciences, Kartal Kosuyolu High Specialty Training and Research Hospital, İstanbul, Turkey
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Liang J, Wang Z, Zhou Y, Shen H, Chai M, Ma X, Han H, Shao Q, Li Q. Efficacy and Safety of Direct Oral Anticoagulants in the Treatment of Left Ventricular Thrombus After Acute Anterior Myocardial Infarction in Patients Who Underwent Percutaneous Coronary Intervention. Curr Vasc Pharmacol 2022; 20:517-526. [PMID: 36200193 DOI: 10.2174/1570161120666221003104821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Revised: 08/27/2022] [Accepted: 08/29/2022] [Indexed: 01/25/2023]
Abstract
AIMS To explore treatment with Direct Oral Anticoagulants (DOACs) in left ventricular thrombus (LVT) after ST-segment elevation myocardial infarction (STEMI) in patients who underwent percutaneous coronary intervention (PCI). BACKGROUND Contemporary data regarding using DOACs for LVT after STEMI patients who underwent PCI is limited. OBJECTIVES To investigate the efficacy and safety of DOACs on the treatment of LVT post STEMI and PCI. METHODS This retrospective study enrolled patients with LVT post STEMI and PCI within 1month from onset who received warfarin or DOACs at discharge. The primary endpoint was LVT resolution. Secondary endpoints were major adverse cardiovascular events (MACEs), including death, stroke, systemic embolism (SE), myocardial infarction (MI) and major or minor bleeding. RESULTS A total of 128 consecutive patients were recruited, of which 72 received warfarin and 56 DOACs [48 on rivaroxaban and 8 on dabigatran]. The rate of LVT resolution was higher within 1 month in the DOACs group than warfarin (26.8% vs. 11.1%; p = 0.022) (Kaplan-Meier estimates, p = 0.002). No significant differences were found at 3 months (p = 0.246), 6 months (p = 0.201), 9 months (p = 0.171) and 12 months (p = 0.442). No patients treated with DOACs had major bleeding, while two patients with warfarin had upper gastrointestinal bleeding (0 vs. 2 (2.8%); p = 0.209). No death or SE occurred. No significant differences on secondary endpoints were found in both the groups, including stroke, MI, minor bleeding and all bleeding events. CONCLUSION DOACs appear to be a suitable alternative to warfarin for the management of LVT post STEMI, especially in patients who are intolerant to warfarin.
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Affiliation(s)
- Jing Liang
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Zhijian Wang
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Yujie Zhou
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Hua Shen
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Meng Chai
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Xiaoteng Ma
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Hongya Han
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Qiaoyu Shao
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
| | - Qiuxuan Li
- Department of Cardiology, Beijng Anzhen Hospital, Beijing Institute of Heart Lung and Blood Vessel Disease, Capital Medical University, Beijing, China
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Li Y, Ren W, Wang X, Xiao Y, Feng Y, Shi P, Sun L, Wang X, Yang H, Song G. The diagnostic accuracy of contrast echocardiography in patients with suspected cardiac masses: A preliminary multicenter, cross-sectional study. Front Cardiovasc Med 2022; 9:1011560. [PMID: 36187014 PMCID: PMC9523017 DOI: 10.3389/fcvm.2022.1011560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/29/2022] [Indexed: 12/04/2022] Open
Abstract
Background To evaluate the diagnostic accuracy of contrast echocardiography (CE) in patients with suspected cardiac masses. Methods A multicenter, prospective study involving 108 consecutive patients with suspected cardiac masses based on transthoracic echocardiography performed between November 2019 and December 2020 was carried out. CE examinations were performed in all patients. The echocardiographic diagnosis was established according to the qualitative (echogenicity, boundary, morphology of the base, mass perfusion, pericardial effusion, and motility) and quantitative (area of the masses and peak intensity ratio of the masses and adjacent myocardium A1/A2) evaluations. Results Final confirmed diagnoses were as follows: no cardiac mass (n = 3), pseudomass (n = 3), thrombus (n = 36), benign tumor (n = 30), and malignant tumor (n = 36). ROC analysis revealed the optimal A1/A2 with cutoff value of 0.295 for a cardiac tumor from a thrombus, with AUC, sensitivity, specificity, PPV, and NPV of 0.958 (95% confidence interval (CI): 0.899–0.988), 100, 91.7, 95.7, and 100%, respectively. CE was able to distinguish malignant from benign tumors with an AUC of 0.953 (95% CI: 0.870–0.990). Multivariate logistic regression analysis revealed that tumor area, base, and A1/A2 were associated with the risk of malignant tumor (OR = 1.003, 95% CI: 1.00003–1.005; OR = 22.64, 95% CI: 1.30–395.21; OR = 165.39, 95% CI: 4.68–5,850.94, respectively). When using A1/A2 > 1.28 as the only diagnostic criterion to identify the malignant tumor, AUC, sensitivity, specificity, PPV, and NPV were 0.886 (95% CI: 0.784–0.951), 80.6, 96.7, 96.7, and 80.7%, respectively. Conclusion CE has the potential to accurately differentiate cardiac masses by combining qualitative and quantitative analyses. However, more studies with a large sample size should be conducted to further confirm these findings. Clinical trial registration http://www.chictr.org.cn/, identifier: ChiCTR1900026809.
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Affiliation(s)
- Ying Li
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Weidong Ren
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Xin Wang
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yangjie Xiao
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
| | - Yueqin Feng
- Department of Ultrasound, The First Hospital of China Medical University, Shenyang, China
| | - Pengli Shi
- Department of Ultrasound, The Fourth Affiliated Hospital of China Medical University, Shenyang, China
| | - Lijuan Sun
- Department of Ultrasound, The First Hospital of Qinhuangdao, Qinhuangdao, China
| | - Xiao Wang
- Department of Ultrasound, Anshan Central Hospital, Anshan, China
| | - Huan Yang
- Department of Ultrasound, Yingkou Central Hospital, Yingkou, China
| | - Guang Song
- Department of Ultrasound, Shengjing Hospital of China Medical University, Shenyang, China
- *Correspondence: Guang Song
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Patel AN, Amrutiya RJ, Manvar BN. A Proposed Approach for the Management of Clot-in-Transit. Cureus 2022; 14:e28481. [PMID: 36176887 PMCID: PMC9512516 DOI: 10.7759/cureus.28481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/26/2022] [Indexed: 12/02/2022] Open
Abstract
Clot-in-transit (CIT) is defined as a mobile echogenic material in the right atrium or ventricle as observed on ultrasound. A right heart free-floating thrombus is unusual when there is no structural disease of the heart or atrial fibrillation. Cardiopulmonary collapse and quick death can come from CIT, which occurs when a blood clot moves from the heart to the lungs. There are some clinical case reports of a large volume thrombus that was freely floating in the right heart in an asymptomatic patient, and the best therapeutic options are uncertain. Although several trials have been conducted on the treatment of CIT, clinical judgment is still used to determine the best treatment for right heart thrombus (RHT), especially when associated with pulmonary embolism (PE). In this review article, we discuss various diagnostic modalities and treatment options for this rare malady. We studied in detail their clinical impact on patients according to past research studies.
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9
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Allard L, Bernhard B, Windecker S, Valgimigli M, Gräni C. Left ventricular thrombus in ischaemic heart disease: diagnosis, treatment, and gaps of knowledge. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:496-509. [PMID: 34928322 DOI: 10.1093/ehjqcco/qcab097] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 12/14/2021] [Accepted: 12/16/2021] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Ludovic Allard
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Stephan Windecker
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
| | - Marco Valgimigli
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland.,Cardiocentro Ticino Institute, Ente Ospedaliero Cantonale and Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland
| | - Christoph Gräni
- Department of Cardiology, University Hospital of Bern, University of Bern, Freiburgstrasse, CH-3010 Bern, Switzerland
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Hooks M, Okasha O, Velangi PS, Nijjar PS, Farzaneh-Far A, Shenoy C. Left ventricular thrombus on cardiovascular magnetic resonance imaging in non-ischaemic cardiomyopathy. Eur Heart J Cardiovasc Imaging 2021; 22:1425-1433. [PMID: 33026088 PMCID: PMC11004928 DOI: 10.1093/ehjci/jeaa244] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 08/06/2020] [Indexed: 11/12/2022] Open
Abstract
AIMS Case reports have described left ventricular (LV) thrombus in patients with non-ischaemic cardiomyopathy (NICM). We aimed to systematically study the characteristics, predictors, and outcomes of LV thrombus in NICM. METHODS AND RESULTS Forty-eight patients with LV thrombus detected on late gadolinium enhancement cardiovascular magnetic resonance imaging (LGE CMR) in NICM were compared with 124 patients with LV thrombus in ischaemic cardiomyopathy (ICM), and 144 matched patients with no LV thrombus in NICM. The performance of echocardiography for the detection of LV thrombus was compared between NICM and ICM. The 12-month incidence of embolism was compared between the three study groups. Independent predictors of LV thrombus in NICM were LV ejection fraction (LVEF) [hazard ratio (HR) 1.36 per 5% decrease; P = 0.002], LGE presence (HR 6.30; P < 0.001), and LGE extent (HR 1.33 per 5% increase; P = 0.001). Compared with patients with LV thrombus in ICM, those with LV thrombus in NICM had a 10-fold higher prevalence of thrombi in other cardiac chambers. The performance of echocardiography for the detection of LV thrombus was not different between NICM and ICM. The 12-month incidence of embolism associated with LV thrombus was not different between NICM and ICM (8.7% vs. 6.8%; P = 0.69) but both were higher compared with no LV thrombus in NICM (1.5%). CONCLUSION Independent predictors of LV thrombus in NICM were lower LVEF, LGE presence, and greater LGE extent. The 12-month incidence of embolism associated with LV thrombus in NICM was not different compared with LV thrombus in ICM.
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Affiliation(s)
- Matthew Hooks
- Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN 55455, USA
| | - Osama Okasha
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
- Department of Medicine, University of Missouri-Kansas City, Kansas City, MO 64108, USA
| | - Pratik S Velangi
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Prabhjot S Nijjar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
| | - Afshin Farzaneh-Far
- Section of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, IL 60612, USA
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, 420 Delaware Street SE, MMC 508, Minneapolis, MN 55455, USA
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11
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De Luca L, Putini RL, Natale E, Terranova A, Piazza V, Pugliese M, De Lio L, Biffani E, Bellettini E, Uguccioni M, Musumeci F. One-year clinical outcome of patients with left ventricular thrombus after acute myocardial infarction discharged on triple or dual antithrombotic therapy. J Thromb Thrombolysis 2021; 53:410-416. [PMID: 34613575 DOI: 10.1007/s11239-021-02577-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2021] [Indexed: 11/30/2022]
Abstract
In patients with left ventricular thrombus (LVT) after acute myocardial infarction (MI), both anticoagulant and antiplatelet therapies are needed. It is unknown whether dual antithrombotic therapy (DAT) is able to reduce the incidence of bleeding complications without significantly increasing the number of thromboembolic events, compared to triple antithrombotic therapy (TAT). We retrospectively evaluated all post-MI patients with LVT discharged on TAT or DAT from our tertiary hospital in the last decade. The primary outcome was the occurrence of all-cause mortality, thromboembolic events, hospitalizations for re-MI or heart failure and any bleeding at 1 year. A propensity-score matching was performed in order to compare the primary outcome between TAT and DAT. Out of 2564 acute MI patients, 83 (3.2%) had an LVT at echocardiography: 51 (61.4%) discharged on TAT and 32 (38.6%) on DAT. At clinical follow-up, completed in 93% of cases, the incidence of the primary outcome was 18.2% (25.5% in TAT and 6.7% in DAT group; p = 0.04). More than 2/3 of the events included in the primary outcome were related to bleeding complications and occurred during the first month from hospital discharge. In the matched cohort of 42 patients with follow-up data available, the primary outcome occurred in 9 (42.9%) patients in the TAT and 2 (9.5%) in the DAT group (p = 0.03). In post-MI patients with LVT, DAT seems more effective than TAT in reducing clinical outcome, especially early bleeding complications. A randomized study is warranted to confirm this hypothesis.
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Affiliation(s)
- Leonardo De Luca
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy.
| | - Rita Lucia Putini
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Enrico Natale
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Antonio Terranova
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Vito Piazza
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Marco Pugliese
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Lucia De Lio
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Elisabetta Biffani
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Elisa Bellettini
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Massimo Uguccioni
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
| | - Francesco Musumeci
- Department of Cardiosciences, Division of Cardiology, Azienda Ospedaliera San Camillo-Forlanini, Circonvallazione Gianicolense, 87, 00152, Rome, Italy
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12
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: executive summary. Europace 2021; 22:450-495. [PMID: 31995197 DOI: 10.1093/europace/euz332] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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13
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Bae DJ, Wadia SK, Kim JS, Moreno E, Ardehali R, Shemin RJ, Kwon MH. Validity of echocardiography for detection of left ventricular thrombus with surgical validation in patients awaiting durable left ventricular assist device. J Card Surg 2021; 36:2722-2728. [PMID: 34047391 DOI: 10.1111/jocs.15662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 04/24/2021] [Accepted: 04/30/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Unrecognized left ventricular thrombi (LVT) can have devastating clinical implications and precludes patients with end-stage heart failure from undergoing left ventricular assist device (LVAD) implantation without cardiopulmonary bypass assistance. We assessed the reliability of an echocardiogram to diagnose LVT in patients with end-stage heart disease who underwent LVAD implantation. METHODS A single-center retrospective study evaluated 232 consecutive adult patients requiring implantation of durable LVADs between 2005 and 2019. The validity of preoperative transthoracic echocardiogram (TTE) and intraoperative transesophageal echocardiogram (TEE) for diagnosing LVT was compared to direct inspection at the time of LVAD implantation. RESULTS There were 232 patients that underwent LVAD implantation, with 226 patients (97%) receiving a preoperative TTE. Of those 226 patients, 32 patients (14%) received ultrasound enhancing agents (UEA). Intraoperative TEE images were available in 195 patients (84%). The sensitivity of TTE without UEA was 22% and specificity was 90% for detecting LVT, compared to 50% and 86%, respectively, for TTE with UEA. For intraoperative TEE, the sensitivity and specificity were 46% and 96%, respectively. The false omission rate ranged from 4% to 8% for all modalities of echocardiography. CONCLUSION Among patients undergoing LVAD implantation, preoperative TTE and intraoperative TEE had poor sensitivity for LVT detection. Up to 8% of echocardiograms were incorrectly concluded to be negative for LVT on surgical validation. The low sensitivity and positive predictive value for diagnosing LVT suggest that echocardiography has limited reliability in this cohort of patients who are at high risk of LVT formation and its subsequent complications.
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Affiliation(s)
- David J Bae
- Division of Cardiology, University of California, Los Angeles, California, USA
| | - Subeer K Wadia
- Division of Cardiology, University of California, Los Angeles, California, USA
| | - Juka S Kim
- David Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Elan Moreno
- Division of Cardiology, University of California, Los Angeles, California, USA
| | - Reza Ardehali
- Division of Cardiology, University of California, Los Angeles, California, USA
| | - Richard J Shemin
- Division of Cardiothoracic Surgery, University of California, Los Angeles, California, USA
| | - Murray H Kwon
- Division of Cardiothoracic Surgery, University of California, Los Angeles, California, USA
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14
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An Z, Gao Z, Wang L, Hou C, Zhang L, Gong S, Rao R, Li C, Qin Z. Prognostic Significance of B-Type Natriuretic Peptide in Patients With Left Ventricular Thrombus. Front Cardiovasc Med 2021; 8:667908. [PMID: 33996952 PMCID: PMC8116499 DOI: 10.3389/fcvm.2021.667908] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 04/06/2021] [Indexed: 11/30/2022] Open
Abstract
Background and Aims: There is sparse information on the prognostic value of B-type natriuretic peptide (BNP) for the outcomes in patients with left ventricular thrombus (LVT). Methods: Patients diagnosed with LVT by transthoracic echocardiography between November 2009 to July 2020 at our institution were included. The endpoints were all-cause mortality and systemic embolism. Results: Ninety-two subjects were finally included in the study. The mean age of the cohort was 56.73 ± 14.12, and 80.4% of the patients were male. The median BNP (1st quartile−3rd quartile) was 437.5 (112.74–1317.5). The total all-cause mortality rate was 30.44% (28/92), and the 1-year, 2-year, and 3-year cumulative survival rates were 85.4, 75.5, and 66.5%, respectively. Systemic embolism was identified in 10 subjects. COX multivariate analysis showed that Log BNP (HR, 4.16; 95%CI, 1.81–9.56; P = 0.001) and BMI (HR, 0.86; 95%CI, 0.73–0.99; P = 0.048) were significantly associated with all-cause mortality. In addition, patients with BNP levels in the upper median (≥ 437.5 pg/ml) had significantly higher all-cause mortality rate compared to those with lower median BNP (<437.5 pg/ml; P = 0.004). The area under the receiver operating characteristic curve for BNP and all-cause mortality was 0.71. In the linear trend test, BNP quartiles were significantly related to all-cause mortality in all models, and the P-values for trend in models 1, 2, and 3 were 0.005, 0.006, and 0.048, respectively. Conclusion: BNP level is a prognostic factor for all-cause mortality in LVT patients, and elevated BNP is indicative of a higher risk of LVT.
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Affiliation(s)
- Zhixia An
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhichun Gao
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Luyu Wang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Changchun Hou
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Liying Zhang
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Cardiology, Shapingba District People's Hospital, Chongqing, China
| | - Siming Gong
- Department of Ultrasound, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Rongsheng Rao
- Department of Ultrasound, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chun Li
- Department of Ultrasound, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhexue Qin
- Department of Cardiology, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Institute of Cardiovascular Diseases of PLA, Xinqiao Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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15
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Endoscopy-assisted removal of multiple left ventricular thrombi through right mini-thoracotomy. Gen Thorac Cardiovasc Surg 2021; 69:1140-1143. [PMID: 33743136 DOI: 10.1007/s11748-021-01622-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Abstract
Left ventricular thrombus is life-threatening when it causes systemic embolization. In cases with a high risk of systemic embolization, left ventricular thrombectomy is recommended. However, the optimal surgical approach is unclear, especially for non-ischemic cardiomyopathy, because left ventriculotomy carries the risk of postoperative cardiac dysfunction. We herein report a male patient with multiple left ventricular thrombi due to acute myocarditis. Endoscopy-assisted left ventricular thrombectomy through right mini-thoracotomy was successfully performed. This method might be an efficient and less-invasive left ventricular thrombectomy for non-ischemic cardiomyopathy.
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16
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Use of Transthoracic Echocardiogram to Detect Left Ventricular Thrombi. Ann Thorac Surg 2021; 111:556-560. [DOI: 10.1016/j.athoracsur.2020.05.106] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 05/06/2020] [Accepted: 05/22/2020] [Indexed: 11/21/2022]
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17
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Yeung W, Sia CH, Pollard T, Leow AST, Tan BYQ, Kaur R, Yeo TC, Tay ELW, Yeo LLL, Chan MYY, Loh JPY. Predicting mortality, thrombus recurrence and persistence in patients with post-acute myocardial infarction left ventricular thrombus. J Thromb Thrombolysis 2021; 52:654-661. [PMID: 33389609 DOI: 10.1007/s11239-020-02368-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 11/27/2022]
Abstract
Left ventricular thrombus (LVT) is a common complication of acute myocardial infarction and is associated with morbidity from embolic complications. Predicting which patients will develop death or persistent LVT despite anticoagulation may help clinicians identify high-risk patients. We developed a random forest (RF) model that predicts death or persistent LVT and evaluated its performance. This was a single-center retrospective cohort study in an academic tertiary center. We included 244 patients with LVT in our study. Patients who did not receive anticoagulation (n = 8) or had unknown (n = 31) outcomes were excluded. The primary outcome was a composite outcome of death, recurrent LVT and persistent LVT. We selected a total of 31 predictors collected at the point of LVT diagnosis based on clinical relevance. We compared conventional regularized logistic regression with the RF algorithm. There were 156 patients who had resolution of LVT and 88 patients who experienced the composite outcome. The RF model achieved better performance and had an AUROC of 0.700 (95% CI 0.553-0.863) on a validation dataset. The most important predictors for the composite outcome were receiving a revascularization procedure, lower visual ejection fraction (EF), higher creatinine, global wall motion abnormality, higher prothrombin time, higher body mass index, higher activated partial thromboplastin time, older age, lower lymphocyte count and higher neutrophil count. The RF model accurately identified patients with post-AMI LVT who developed the composite outcome. Further studies are needed to validate its use in clinical practice.
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Affiliation(s)
- Wesley Yeung
- University Medicine Cluster, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore. .,Laboratory for Computational Physiology, Harvard-MIT Health Sciences & Technology, Massachusetts Institute of Technology, Cambridge, MA, USA.
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Tom Pollard
- Laboratory for Computational Physiology, Harvard-MIT Health Sciences & Technology, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Aloysius Sheng-Ting Leow
- University Medicine Cluster, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074, Singapore
| | - Benjamin Yong-Qiang Tan
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Rajinderdeep Kaur
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Edgar Lik-Wui Tay
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Leonard Leong-Litt Yeo
- Yong Loo Lin School of Medicine, National University Singapore, Singapore, Singapore.,Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Joshua Ping-Yun Loh
- Department of Cardiology, National University Heart Centre Singapore, Singapore, Singapore.,Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
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18
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Sáenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Europace 2020; 21:1143-1144. [PMID: 31075787 DOI: 10.1093/europace/euz132] [Citation(s) in RCA: 267] [Impact Index Per Article: 53.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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19
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary. J Interv Card Electrophysiol 2020; 59:81-133. [PMID: 31960344 PMCID: PMC7508755 DOI: 10.1007/s10840-019-00664-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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20
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Bella PD, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. J Interv Card Electrophysiol 2020; 59:145-298. [PMID: 31984466 PMCID: PMC7223859 DOI: 10.1007/s10840-019-00663-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, AL, USA
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, IN, USA
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, CA, USA
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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21
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Sia CH, Leow AST, Tan BYQ, Low CJ, Kaur R, Yeo TC, Chan MYY, Tay ELW, Yeo LLL, Yap ES, Loh JPY. The neutrophil-lymphocyte ratio and platelet-lymphocyte ratio predict left ventricular thrombus resolution in acute myocardial infarction without percutaneous coronary intervention. Thromb Res 2020; 194:16-20. [PMID: 32559523 DOI: 10.1016/j.thromres.2020.06.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Revised: 05/18/2020] [Accepted: 06/01/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Left ventricular thrombosis (LVT) is a potentially devastating complication in post-acute myocardial infarction (AMI) patients. Previous studies have demonstrated that inflammation may contribute to thrombus formation, but its role on thrombus resolution is uncertain. The neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) are easily accessible haematological markers of inflammation. OBJECTIVES We aimed to identify differences between post-AMI LVT patients with and without LVT resolution, and to evaluate the utility of NLR and PLR in predicting LVT resolution. METHODS We included 289 consecutive post-AMI patients with LVT. Acute LVT was diagnosed based on echocardiogram. Patients were stratified based on LVT resolution. Logistic regression was performed to evaluate for independent predictors of thrombus resolution. RESULTS Compared to post-AMI patients with eventual LVT resolution, those with unresolved LVT had more co-morbidities such as hypertension (p = 0.003) and ischaemic heart disease (p < 0.001), fewer underwent percutaneous coronary intervention (PCI) (p < 0.001) or were treated with triple therapy (p < 0.001). NLR (p = 0.064) and PLR (p = 0.028) were higher in unresolved LVT patients. In non-PCI patients, NLR (OR 0.818, 95% CI 0.674-0.994, p = 0.043) and PLR (OR 0.989, 95% CI 0.979-0.999, p = 0.026) were independent predictors of thrombus resolution after adjustment for age and anticoagulation use. CONCLUSIONS Post-AMI patients not receiving PCI may have a greater inflammatory response and a higher NLR and PLR, which is associated with less LVT resolution despite anticoagulation. Further studies are required to study this association.
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Affiliation(s)
- Ching-Hui Sia
- Department of Cardiology, National University Heart Centre, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore.
| | | | | | | | - Rajinderdeep Kaur
- Department of Cardiology, National University Heart Centre, Singapore, Singapore
| | - Tiong-Cheng Yeo
- Department of Cardiology, National University Heart Centre, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Mark Yan-Yee Chan
- Department of Cardiology, National University Heart Centre, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Edgar Lik-Wui Tay
- Department of Cardiology, National University Heart Centre, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Leonard Leong-Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Eng-Soo Yap
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore; Department of Haematology-Oncology, National University Cancer Institute, Singapore
| | - Joshua Ping-Yun Loh
- Department of Cardiology, National University Heart Centre, Singapore, Singapore; Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
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Hudec S, Hutyra M, Precek J, Latal J, Nykl R, Spacek M, Sluka M, Sanak D, Tudos Z, Navratil K, Pavlu L, Taborsky M. Acute myocardial infarction, intraventricular thrombus and risk of systemic embolism. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2020; 164:34-42. [DOI: 10.5507/bp.2020.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2019] [Accepted: 01/03/2020] [Indexed: 01/02/2023] Open
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23
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Aksu F, Oktay A, Caliskan M. Right atrial mass imitating the catheter. INTERNATIONAL JOURNAL OF THE CARDIOVASCULAR ACADEMY 2020. [DOI: 10.4103/ijca.ijca_59_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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24
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Velangi PS, Choo C, Chen KHA, Kazmirczak F, Nijjar PS, Farzaneh-Far A, Okasha O, Akçakaya M, Weinsaft JW, Shenoy C. Long-Term Embolic Outcomes After Detection of Left Ventricular Thrombus by Late Gadolinium Enhancement Cardiovascular Magnetic Resonance Imaging: A Matched Cohort Study. Circ Cardiovasc Imaging 2019; 12:e009723. [PMID: 31707810 PMCID: PMC6941143 DOI: 10.1161/circimaging.119.009723] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging is more sensitive than echocardiography for the detection of intracardiac thrombus because of its unique ability to identify thrombus based on tissue characteristics related to avascularity. The long-term prognostic significance of left ventricular (LV) thrombus detected by LGE CMR is unknown. METHODS We performed a matched cohort study of consecutive adult patients with LV thrombus detected by LGE CMR who were matched on the date of CMR, age, and LV ejection fraction to up to 3 patients without LV thrombus. We investigated the long-term incidence of a composite of embolic events: stroke, transient ischemic attack, or extracranial systemic arterial embolism. We also compared outcomes among patients with LV thrombus detected by LGE CMR stratified by whether the LV thrombus was also detected by echocardiography or not. RESULTS Of 157 LV thrombus patients, 155 were matched to 400 non-LV thrombus patients. During a median follow-up of 3.3 years, the cumulative incidence of embolism was significantly higher in LV thrombus patients compared with the matched non-LV thrombus patients (P<0.001), with annualized rates of 3.7% and 0.8% for LV thrombus and matched non-LV thrombus patients, respectively. LV thrombus was the only independent predictor of the composite embolic end point (hazard ratio, 3.99 [95% CI, 1.54-10.35]; P=0.004). The cumulative incidence of embolism was not different in patients with LV thrombus that was also detected by echocardiography versus patients with LV thrombus not detected by echocardiography (P=0.25). CONCLUSIONS Despite contemporary antithrombotic treatment, LV thrombus detected by LGE CMR is associated with a 4-fold higher long-term incidence of embolism compared with matched non-LV thrombus patients. LV thrombus detected by LGE CMR but not by echocardiography is associated with a similar risk of embolism as that detected by both LGE CMR and echocardiography.
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Affiliation(s)
- Pratik S. Velangi
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Christopher Choo
- Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Ko-Hsuan A. Chen
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Felipe Kazmirczak
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Prabhjot S. Nijjar
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Afshin Farzaneh-Far
- Section of Cardiology, Department of Medicine, University of Illinois at Chicago, Chicago, Illinois and Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina
| | - Osama Okasha
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
| | - Mehmet Akçakaya
- Department of Electrical and Computer Engineering and Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Jonathan W. Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Chetan Shenoy
- Cardiovascular Division, Department of Medicine, University of Minnesota Medical Center, Minneapolis, Minnesota, USA
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25
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Maniwa N, Fujino M, Nakai M, Nishimura K, Miyamoto Y, Kataoka Y, Asaumi Y, Tahara Y, Nakanishi M, Anzai T, Kusano K, Akasaka T, Goto Y, Noguchi T, Yasuda S. Anticoagulation combined with antiplatelet therapy in patients with left ventricular thrombus after first acute myocardial infarction. Eur Heart J 2019; 39:201-208. [PMID: 29029233 DOI: 10.1093/eurheartj/ehx551] [Citation(s) in RCA: 102] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Accepted: 09/07/2017] [Indexed: 01/08/2023] Open
Abstract
Aims There are limited data about the optimal anti-thrombotic therapy for preventing embolism while minimizing bleeding events in patients with first acute myocardial infarction (AMI) complicated by left ventricular thrombus (LVT). Methods and results Among 2301 consecutive patients with AMI hospitalized between 2001 and 2014, we studied 1850 patients with first AMI who discharged alive to investigate clinical characteristics, incidence of systemic embolism (SE), and association between anticoagulation and embolic or bleeding events. Left ventricular thrombus was diagnosed by echocardiography, left ventriculography, or cardiac magnetic resonance imaging in 92 (5.0%) patients (62 ± 12 years). During a median follow-up period of 5.4 years (interquartile range 2.1-9.1 years), SE occurred in 15 of 92 patients with LVT (16.3%) and 51 of 1758 patients without LVT (2.9%), respectively. Kaplan-Meier analysis showed a significantly higher incidence of SE in the LVT group (log-rank test, P < 0.001). Multivariate analysis showed that LVT was an independent predictor of SE. Among the LVT patients treated with vitamin K antagonists (n = 84), we compared the patients with therapeutic range (TTR) ≥50% (n = 34) and those with TTR <50% (n = 50). Only one embolic event developed in the TTR ≥50% group and nine embolic events developed in the TTR <50% group (2.9% vs. 19%, P = 0.036). There was no difference in major bleeding events (TTR ≥50%; 9% vs. TTR <50%; 8%, P = 0.89). Conclusion Appropriate anticoagulation therapy may decrease the incidence of embolic events without increasing the incidence of bleeding events in patients with first AMI complicated by LV thrombus.
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Affiliation(s)
- Naoki Maniwa
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Masashi Fujino
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Michikazu Nakai
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Kunihiro Nishimura
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Yoshihiro Miyamoto
- Department of Statistics and Data Analysis, Center for Cerebral and Cardiovascular Disease Information, National Cerebral and Cardiovascular Center, 5-7-1 Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Yu Kataoka
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Yasuhide Asaumi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Yoshio Tahara
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Michio Nakanishi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Toshihisa Anzai
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Kengo Kusano
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Takashi Akasaka
- Department of Cardiology, Wakayama Medical University, 811-1 Kimiidera, Wakayama 641-8510, Japan
| | - Yoichi Goto
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Teruo Noguchi
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
| | - Satoshi Yasuda
- Department of Cardiovascular Medicine, National Cerebral and Cardiovascular Center, 5-7-1, Fujishirodai, Suita, Osaka 565-8565, Japan
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias: Executive summary. Heart Rhythm 2019; 17:e155-e205. [PMID: 31102616 PMCID: PMC8459311 DOI: 10.1016/j.hrthm.2019.03.014] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Indexed: 12/16/2022]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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27
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Cronin EM, Bogun FM, Maury P, Peichl P, Chen M, Namboodiri N, Aguinaga L, Leite LR, Al-Khatib SM, Anter E, Berruezo A, Callans DJ, Chung MK, Cuculich P, d'Avila A, Deal BJ, Della Bella P, Deneke T, Dickfeld TM, Hadid C, Haqqani HM, Kay GN, Latchamsetty R, Marchlinski F, Miller JM, Nogami A, Patel AR, Pathak RK, Saenz Morales LC, Santangeli P, Sapp JL, Sarkozy A, Soejima K, Stevenson WG, Tedrow UB, Tzou WS, Varma N, Zeppenfeld K. 2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias. Heart Rhythm 2019; 17:e2-e154. [PMID: 31085023 PMCID: PMC8453449 DOI: 10.1016/j.hrthm.2019.03.002] [Citation(s) in RCA: 220] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Indexed: 01/10/2023]
Abstract
Ventricular arrhythmias are an important cause of morbidity and mortality and come in a variety of forms, from single premature ventricular complexes to sustained ventricular tachycardia and fibrillation. Rapid developments have taken place over the past decade in our understanding of these arrhythmias and in our ability to diagnose and treat them. The field of catheter ablation has progressed with the development of new methods and tools, and with the publication of large clinical trials. Therefore, global cardiac electrophysiology professional societies undertook to outline recommendations and best practices for these procedures in a document that will update and replace the 2009 EHRA/HRS Expert Consensus on Catheter Ablation of Ventricular Arrhythmias. An expert writing group, after reviewing and discussing the literature, including a systematic review and meta-analysis published in conjunction with this document, and drawing on their own experience, drafted and voted on recommendations and summarized current knowledge and practice in the field. Each recommendation is presented in knowledge byte format and is accompanied by supportive text and references. Further sections provide a practical synopsis of the various techniques and of the specific ventricular arrhythmia sites and substrates encountered in the electrophysiology lab. The purpose of this document is to help electrophysiologists around the world to appropriately select patients for catheter ablation, to perform procedures in a safe and efficacious manner, and to provide follow-up and adjunctive care in order to obtain the best possible outcomes for patients with ventricular arrhythmias.
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Affiliation(s)
| | | | | | - Petr Peichl
- Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minglong Chen
- Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Narayanan Namboodiri
- Sree Chitra Institute for Medical Sciences and Technology, Thiruvananthapuram, India
| | | | | | | | - Elad Anter
- Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | | | | | | | | | - Andre d'Avila
- Hospital Cardiologico SOS Cardio, Florianopolis, Brazil
| | - Barbara J Deal
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | - Claudio Hadid
- Hospital General de Agudos Cosme Argerich, Buenos Aires, Argentina
| | - Haris M Haqqani
- University of Queensland, The Prince Charles Hospital, Chermside, Australia
| | - G Neal Kay
- University of Alabama at Birmingham, Birmingham, Alabama
| | | | | | - John M Miller
- Indiana University School of Medicine, Krannert Institute of Cardiology, Indianapolis, Indiana
| | | | - Akash R Patel
- University of California San Francisco Benioff Children's Hospital, San Francisco, California
| | | | | | | | - John L Sapp
- Queen Elizabeth II Health Sciences Centre, Halifax, Canada
| | - Andrea Sarkozy
- University Hospital Antwerp, University of Antwerp, Antwerp, Belgium
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Oh JK, Park JH, Lee JH, Kim J, Seong IW. Shape and Mobility of a Left Ventricular Thrombus Are Predictors of Thrombus Resolution. Korean Circ J 2019; 49:829-837. [PMID: 31074225 PMCID: PMC6713824 DOI: 10.4070/kcj.2018.0346] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 03/06/2019] [Accepted: 03/20/2019] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Left ventricular (LV) apical thrombi are usually present with LV dilatation, and oral anticoagulants reduce embolic risk in these patients. However, echocardiographic data regarding thrombus resolution remain limited. We studied its echocardiographic features that were associated with early resolution (within 1 month). METHODS We performed a retrospective observational study by reviewing baseline and follow-up echocardiographic images and medical records in patients with LV apical thrombi. RESULTS Between January 2005 and December 2017, 77 patients (59 males, mean 61±12 years old) were enrolled. Patients were classified into 2 groups based on duration of thrombus resolution: group 1 showing resolution within 1 month (n=23) and group 2 with persistence after 1 month (n=54). Thrombus size was significantly smaller in group 1 (10.7±4.2 vs. 12.1±5.5 mm, p=0.046). Grade 1 mobility (partially mobile; odds ratio [OR], 7.800; p=0.012) and grade 2 mobility (highly mobile; OR, 14.625; p=0.002) were significantly associated with the early resolution. Round thrombi were associated with early resolution than mural form (OR, 3.187; p=0.026). Multivariate analysis showed that the mobility was the most important parameter, and a highly mobile (grade 2 mobility) LV apical thrombi showed earlier resolution (OR, 12.525; p=0.013). During the follow-up over 62±44 months, 25 patients (32.5%) had ≥1 adverse clinical events. The late resolution of thrombi was associated with poor long-term clinical outcomes (hazard ratio, 5.727; p=0.020). CONCLUSIONS Mobility of LV apical thrombi was the most important parameter associated with early thrombus resolution. Late resolution of LV apical thrombi was associated with poor long-term clinical outcomes.
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Affiliation(s)
- Jin Kyung Oh
- Department of cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jae Hyeong Park
- Department of cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea.
| | - Jae Hwan Lee
- Department of cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - Jeongai Kim
- Department of cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
| | - In Whan Seong
- Department of cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University School of Medicine, Daejeon, Korea
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Characterisation of acute ischemic stroke in patients with left ventricular thrombi after myocardial infarction. J Thromb Thrombolysis 2019; 48:158-166. [DOI: 10.1007/s11239-019-01829-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Zhang Q, Wang C, Shi S, Chen H, Zhou Y. Relationship of left ventricular thrombus formation and adverse outcomes in acute anterior myocardial infarction in patients treated with primary percutaneous coronary intervention. Clin Cardiol 2019; 42:69-75. [PMID: 30367476 PMCID: PMC6436520 DOI: 10.1002/clc.23106] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 10/17/2018] [Accepted: 10/23/2018] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND The incidence of left ventricular thrombus (LVT) is 4% to 15% in patients with anterior acute ST-segment elevation myocardial infarction (ant-AMI) in the era of primary percutaneous coronary intervention (PPCI). And patients with LVT have higher in-hospital mortality. HYPOTHESIS There is a relationship between LVT formation and 1-year major adverse cardio-cerebrovascular events (MACCE) in patients with ant-AMI treated by PPCI. METHODS Our study population included 1488 consecutive patients with ant-AMI. The primary endpoint was the incidence of MACCE within 1 year after AMI. The secondary endpoint was the thrombosis disappearance. RESULTS A total of 106 (7.1%) patients were diagnosed with LVT and 1382 (92.9%) patients without LVT. Patients with LVT had a higher incidence of MACCE than in patients without LVT (21.7%vs10.3%; P < 0.001). Univariate analysis showed LVT was associated with an increase in MACCE risk (odds ratio [OR] = 2.40; 95% confidence interval [CI] [1.37-4.21]; P < 0.001). When examining MACCE components individually, LVT was only associated with the incidence of congestive heart failure (OR = 2.41; 95% CI [1.29-4.58]; P = 0.001). After adjustment for principal confounders, LVT remained an independent risk factor for MACCE (HR = 2.28; 95% CI [1.12-6.38]; P = 0.020). Other independent predictors include 24-hour LVEF, creatine kinase peak value, and age. Further analysis found patients with LVT in international normalized ratio (INR) ≥ 2 group had lower MACCE risk and higher thrombus disappearance than in INR < 2 group (13.5%vs29.6%; P = 0.044; 90.4%vs74.1%; P = 0.029). CONCLUSION For patients with ant-AMI treated by PPCI, LVT is an independent predictor of 1-year MACCE events. Treatment with vitamin K antagonist in the therapeutic range (INR ≥ 2) has the potential to reduce MACCE risk and promote disappearance of thrombus.
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Affiliation(s)
- Qian Zhang
- Department of Emergency, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Chun‐Mei Wang
- Department of Emergency, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Shu‐Tian Shi
- Department of Emergency, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Hong Chen
- Department of Emergency, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Yu‐Jie Zhou
- Department of Cardiology, Beijing Anzhen HospitalCapital Medical University, Beijing Institute of Heart Lung and Blood Vessel DiseaseBeijingChina
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Siddiqui I, Nguyen T, Movahed A, Kabirdas D. Elusive left ventricular thrombus: Diagnostic role of cardiac magnetic resonance imaging-A case report and review of the literature. World J Clin Cases 2018; 6:127-131. [PMID: 29988880 PMCID: PMC6033750 DOI: 10.12998/wjcc.v6.i6.127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2018] [Revised: 03/24/2018] [Accepted: 04/11/2018] [Indexed: 02/05/2023] Open
Abstract
Identification of left ventricular mural thrombus (LVT) may be challenging depending on the imaging modality used. We present a case of LVT which was incidentally identified on cine cardiac magnetic resonance imaging (CMR). A sixty-four years old female presented with worsening dyspnea on exertion with troponin elevation. Transthoracic echocardiography (TTE) revealed a dilated left ventricle (LV) and ejection fraction (EF 30%) with thinning and akinesis of inferior/inferolateral wall was noted with basal and mid inferior wall aneurysm, and thrombus was not identified. CMR done to ascertain viability of myocardium revealed a mural thrombus within basal inferior aneurysm. This was not visualized on transthoracic echocardiography with and without use of contrast. She underwent coronary artery bypass grafting, bioprosthetic mitral valve replacement, resection and plication of posterior left ventricular aneurysm with removal of mural thrombus, and was started on anticoagulation with warfarin post-operatively for the apical thrombi. Cardiac magnetic resonance is a well suited imaging modality in detecting LVT due to its high resolution images and is more reproducible than TTE. In our patient, conventional TTE despite administration of echo-contrast agents failed to diagnose the presence of LVT in the basal inferior aneurysm as well as the apical thrombi. Delayed-enhancement CMR provides the greatest sensitivity for detection of left ventricular thrombus, superior to standard transthoracic and contrast-enhanced transthoracic echocardiography.
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Affiliation(s)
- Irfan Siddiqui
- Department of Cardiovascular Sciences, East Carolina University, Brody School of Medicine, East Carolina Heart Institute, Greenville, NC 27858, United States
| | - Tin Nguyen
- Department of Cardiovascular Sciences, East Carolina University, Brody School of Medicine, East Carolina Heart Institute, Greenville, NC 27858, United States
| | - Assad Movahed
- Department of Cardiovascular Sciences, East Carolina University, Brody School of Medicine, East Carolina Heart Institute, Greenville, NC 27858, United States
| | - Deepa Kabirdas
- Department of Cardiovascular Sciences, East Carolina University, Brody School of Medicine, East Carolina Heart Institute, Greenville, NC 27858, United States
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Wu H, Deng D, Song Z, Cao H, Qin L. Thrombus detachment causing lower limb embolism in acute myocardial infarction. Br J Hosp Med (Lond) 2018. [PMID: 29528735 DOI: 10.12968/hmed.2018.79.3.168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Haidi Wu
- Cardiology Registrar, Department of Cardiology, First Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Dayong Deng
- Radiology Registrar, Department of Radiology, Jilin Provincial Cancer Hospital, Changchun, Jilin, People's Republic of China
| | - Zikai Song
- Cardiology Registrar, Department of Cardiology, First Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Hongyan Cao
- Cardiology Registrar, Department of Cardiology, First Hospital of Jilin University, Changchun, Jilin, People's Republic of China
| | - Ling Qin
- Consultant Cardiologist, Department of Cardiology, First Hospital of Jilin University, Changchun, Jilin 130021, People's Republic of China
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Eskandari M, Monaghan MJ. Contrast Echocardiography. Echocardiography 2018. [DOI: 10.1007/978-3-319-71617-6_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Takasugi J, Yamagami H, Noguchi T, Morita Y, Tanaka T, Okuno Y, Yasuda S, Toyoda K, Gon Y, Todo K, Sakaguchi M, Nagatsuka K. Detection of Left Ventricular Thrombus by Cardiac Magnetic Resonance in Embolic Stroke of Undetermined Source. Stroke 2017; 48:2434-2440. [PMID: 28818863 DOI: 10.1161/strokeaha.117.018263] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/08/2017] [Accepted: 07/19/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to use contrast-enhanced cardiac magnetic resonance (CE-CMR) imaging to elucidate the prevalence of left ventricular (LV) thrombus in patients suspected of embolic stroke of undetermined source (ESUS) with previous myocardial infarction or LV dysfunction (LV ejection fraction [LVEF] <50%). METHODS We prospectively investigated 797 consecutive patients who presented to our hospital with acute ischemic stroke between 2014 and 2015. Patients with myocardial infarction or LVEF<50% underwent CE-CMR imaging. ESUS was diagnosed according to proposal criteria based on transthoracic echocardiography findings. RESULTS The prevalence of ESUS was 22% (178 of 797) on initial diagnosis. Among 60 patients with myocardial infarction or LVEF<50%, the stroke subtypes were as follows: small artery disease, 17% (10 of 60); large artery atherosclerosis, 5% (3 of 60); cardioembolic stroke, 49% (29 of 60); ESUS, 23% (14 of 60); and undetermined causes other than ESUS, 6% (4 of 60). Of 60 patients examined via CE-CMR, LV thrombus was confirmed in 12 patients, whereas only 1 had been detected on transthoracic echocardiography (P=0.04). Importantly, 29% (4 of 14) of patients with ESUS had LV thrombus. A prediction model based on CE-CMR findings showed higher performance in LV thrombus detection, permitting a net improvement of 0.46 (95% confidence interval, 0.08-0.82; P=0.016) in cardioembolic stroke reclassification. Compared with patients without LV thrombus, those with LV thrombus had lower LVEF (median: 26% versus 40%; P=0.003). Notably, 42% (5 of 12) of patients with LV thrombus had LVEF≥30%. CONCLUSIONS When ESUS-suspected patients have myocardial infarction or LV dysfunction, CE-CMR may help improve detection of cardioembolic stroke and provide relevant information for anticoagulation therapy. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02251665.
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Affiliation(s)
- Junji Takasugi
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Hiroshi Yamagami
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.).
| | - Teruo Noguchi
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Yoshiaki Morita
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Tomotaka Tanaka
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Yoshinori Okuno
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Satoshi Yasuda
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Kazunori Toyoda
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Yasufumi Gon
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Kenichi Todo
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Manabu Sakaguchi
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
| | - Kazuyuki Nagatsuka
- From the Departments of Neurology (J.T., H.Y., T.T., Y.O., K.N.), Cerebrovascular Medicine (K.T.), Cardiovascular Medicine (T.N., S.Y.), and Radiology (Y.M.), National Cerebral and Cardiovascular Center, Osaka, Japan; and Department of Neurology, Osaka University Graduate School of Medicine, Japan (J.T., Y.G., K.T., M.S.)
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Po JRF, Tong MS, Grove EL, Biederman RWW. Incremental value of contrast echocardiography in the evaluation of a cardiac thrombus. Echocardiography 2017; 34:296-298. [DOI: 10.1111/echo.13431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Hur J, Hong YJ, Im DJ, Lee HJ, Kim YJ, Choi BW. Technological Improvements in Cardiac Thrombus Diagnosis. ACTA ACUST UNITED AC 2017. [DOI: 10.22468/cvia.2017.00031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Jin Hur
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Yoo Jin Hong
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Jin Im
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Hye-Jeong Lee
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Jin Kim
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Byoung Wook Choi
- Department of Radiology, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Foster E, Nanevicz T. The Role of Echocardiography in Acute Myocardial Infarction. J Intensive Care Med 2016. [DOI: 10.1177/088506669801300303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The indications for echocardiography in the setting of acute myocardial infarction are to identify wall motion abnormalities, to evaluate left and right ventricular function, and to exclude complications such as pericarditis, mitral regurgitation, and ventricular rupture. Doppler echocardiography can provide important hemodynamic information. In the near future, contrast echocardiography can be expected to delineate myocardial perfusion and three-dimensional echocardiography to better define infarct size.
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Affiliation(s)
- Elyse Foster
- University of California at San Francisco, San Francisco, CA
| | - Tania Nanevicz
- University of California at San Francisco, San Francisco, CA
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Meenan RT, Saha S, Chou R, Swarztrauber K, Pyle Krages K, O'Keeffe-Rosetti MC, McDonagh M, Chan BKS, Hornbrook MC, Helfand M. Cost-Effectiveness of Echocardiography to Identify Intracardiac Thrombus among Patients with First Stroke or Transient Ischemic Attack. Med Decis Making 2016; 27:161-77. [PMID: 17409366 DOI: 10.1177/0272989x06297388] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
Background and Purpose . Echocardiography to select stroke patients for targeted treatments, such as anticoagulation (AC), to reduce recurrent stroke risk is controversial. The authors' objective was to evaluate the cost-effectiveness of imaging strategies that use transthoracic (TTE) and transesophageal (TEE) echocardiography for identifying intracardiac thrombus in new stroke patients. Methods . Model-based cost-effectiveness analysis of 7 echocardiographic imaging strategies and 2 nontesting strategies with model parameters based on systematic evidence review related to effectiveness of echocardiography in newly diagnosed ischemic stroke patients (white males aged 65 years in base case). Primary outcome was cost per quality-adjusted life year (QALY). Results . All strategies containing TTE were dominated by others and were eliminated from the analysis. Assuming that AC reduces recurrent stroke risk from intracardiac thrombus by 43% over 1 year, TEE generated a cost per QALY of $137,000 (relative to standard treatment) among patients with 5% thrombus prevalence. Cost per QALY dropped to $50,000 in patients with at least 15% intracardiac thrombus prevalence, or, if an 86% relative risk reduction with AC is assumed, in patients with thrombus prevalence of at least 6%. Probabilistic analyses indicate considerable uncertainty around the cost-effectiveness of echocardiography across a wide range of intracardiac thrombus prevalence (pretest probability). Conclusions . Current evidence on cost-effectiveness is insufficient to justify widespread use of echocardiography in stroke patients. Additional research on recurrent stroke risk in patients with intracardiac thrombus and on the efficacy of AC in reducing that risk may contribute to a better understanding of the circumstances under which echocardiography will be cost-effective. Key words: cost-effectiveness; decision analysis; stroke; transesophageal echocardiography; transthoracic echocardiography; diagnostic imaging. (Med Decis Making 2007;27:161—177)
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Affiliation(s)
- Richard T Meenan
- Oregon Health & Science University Evidence-based Practice Center, Portland, USA.
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Improved Detection by Delayed-Enhancement CMR of LV Thrombus Post-MI. JACC Cardiovasc Imaging 2016; 9:516-8. [DOI: 10.1016/j.jcmg.2015.07.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2015] [Revised: 07/30/2015] [Accepted: 07/30/2015] [Indexed: 11/22/2022]
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Ischemic Left Ventricular Perforation Covered by a Thrombus in a Patient Presenting with Cerebral Ischemia: Importance of Time-Sensitive Performance and Adequate Interpretation of Bedside Transthoracic Echography. Case Rep Emerg Med 2016; 2016:7565042. [PMID: 26966599 PMCID: PMC4757730 DOI: 10.1155/2016/7565042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2015] [Revised: 01/12/2016] [Accepted: 01/13/2016] [Indexed: 11/22/2022] Open
Abstract
If myocardial infarction remains silent, only clinical signs of complications may unveil its presence. Life-threatening complications include myocardial rupture, thrombus formation, or arterial embolization. In the presented case, a 76-year-old patient was admitted with left-sided hemiparesis. In duplex sonography, a critical stenosis of the right internal carotid artery was identified and initially but retrospectively incorrectly judged as the potential cause for ischemia. During operative thromboendarterectomy, arterial embolism of the right leg occurred coincidentally, more likely pointing towards a cardioembolic origin. Percutaneous interventions remained unsuccessful and local fibrinolysis was applied. Delayed bedside echocardiography by an experienced cardiologist demonstrated a discontinuity of the normal myocardial texture of the left ventricular apex together with an echodense, partly floating structure merely attached by a thin bridge not completely sealing the myocardial defect, accompanied by pericardial effusion. The patient was immediately transferred to emergency cardiac surgery with extirpation of the thrombus, aortocoronary bypass graft placement, and aneurysmectomy. This didactic case reveals decisive structural shortcomings in patient's admission and triage processes and underlines, if performed timely and correctly, the value of transthoracic echocardiography as a noninvasive and cost-effective tool allowing immediate decision-making, which, in this case, led to the correct but almost fatally delayed diagnosis.
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Echocardiographic Detection of Left Ventricular Thrombus in Patients Undergoing Heartmate II Left Ventricular Assist Device Implantation. Int J Artif Organs 2016; 39:491-496. [DOI: 10.5301/ijao.5000526] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/28/2016] [Indexed: 12/11/2022]
Abstract
Purpose Transthoracic (TTE) and transesophageal echocardiograms (TEE) are considered accurate in detecting the presence of left ventricular (LV) thrombus. A persistent LV thrombus poses risks of pump thrombosis and stroke in LVAD recipients. The relationship between pre-operative echocardiography and intraoperative findings at LVAD implantation has not previously been studied. Methods A retrospective review examined all patients undergoing LVAD placement or exchange from October 2011 to March 2014. Pre-Operative TTE and TEE data were validated with presence of LV thrombus during the direct inspection at the time of LVAD placement, and the findings were analyzed quantitatively. Results Between October 2011 and March 2014, 99 patients underwent a total of 107 LVAD implants. Pre-Operative TTE was available in 93 (86.9%) cases, while pre-operative TEE was available in 37 cases (34.6%). On pre-operative TTE, LV thrombus was correctly identified in only two cases, while on pre-operative TEE no cases of LV thrombus were identified correctly, and there were 2 false positive reports. Intraoperative inspection revealed presence of LV thrombus in 14 cases. The sensitivity of pre-operative TTE was 16.7% and the specificity 100% in detecting LVT, compared to 0% and 93.8%, respectively, for TEE. Conclusions Pre-Operative echocardiogram offers low accuracy for presence of LV thrombus. Overall, the sensitivity is too low to reliably exclude thrombus. This could have significant implications in planning off-pump LVAD exchange as thrombus could be missed. More data are necessary to determine whether this could have significant effects on thromboembolic complications and survival.
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Weinsaft JW, Kim J, Medicherla CB, Ma CL, Codella NCF, Kukar N, Alaref S, Kim RJ, Devereux RB. Echocardiographic Algorithm for Post-Myocardial Infarction LV Thrombus: A Gatekeeper for Thrombus Evaluation by Delayed Enhancement CMR. JACC Cardiovasc Imaging 2015; 9:505-15. [PMID: 26476503 DOI: 10.1016/j.jcmg.2015.06.017] [Citation(s) in RCA: 145] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 06/09/2015] [Accepted: 06/18/2015] [Indexed: 11/30/2022]
Abstract
OBJECTIVES The goal of this study was to determine the prevalence of post-myocardial infarction (MI) left ventricular (LV) thrombus in the current era and to develop an effective algorithm (predicated on echocardiography [echo]) to discern patients warranting further testing for thrombus via delayed enhancement (DE) cardiac magnetic resonance (CMR). BACKGROUND LV thrombus affects post-MI management. DE-CMR provides thrombus tissue characterization and is a well-validated but an impractical screening modality for all patients after an MI. METHODS A same-day echo and CMR were performed according to a tailored protocol, which entailed uniform echo contrast (irrespective of image quality) and dedicated DE-CMR for thrombus tissue characterization. RESULTS A total of 201 patients were studied; 8% had thrombus according to DE-CMR. All thrombi were apically located; 94% of thrombi occurred in the context of a left anterior descending (LAD) infarct-related artery. Although patients with thrombus had more prolonged chest pain and larger MI (p ≤ 0.01), only 18% had aneurysm on echo (cine-CMR 24%). Noncontrast (35%) and contrast (64%) echo yielded limited sensitivity for thrombus on DE-CMR. Thrombus was associated with stepwise increments in basal → apical contractile dysfunction on echo and quantitative cine-CMR; the echo-measured apical wall motion score was higher among patients with thrombus (p < 0.001) and paralleled cine-CMR decrements in apical ejection fraction and peak ejection rates (both p < 0.005). Thrombus-associated decrements in apical contractile dysfunction were significant even among patients with LAD infarction (p < 0.05). The echo-based apical wall motion score improved overall performance (area under the curve 0.89 ± 0.44) for thrombus compared with ejection fraction (area under the curve 0.80 ± 0.61; p = 0.01). Apical wall motion partitions would have enabled all patients with LV thrombus to be appropriately referred for DE-CMR testing (100% sensitivity and negative predictive value), while avoiding further testing in more than one-half (56% to 63%) of patients. CONCLUSIONS LV thrombus remains common, especially after LAD MI, and can occur even in the absence of aneurysm. Although DE-CMR yielded improved overall thrombus detection, apical wall motion on a noncontrast echocardiogram can be an effective stratification tool to identify patients in whom DE-CMR thrombus assessment is most warranted. (Diagnostic Utility of Contrast Echocardiography for Detection of LV Thrombi Post ST Elevation Myocardial Infarction; NCT00539045).
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Affiliation(s)
- Jonathan W Weinsaft
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Radiology, Weill Cornell Medical College, New York, New York.
| | - Jiwon Kim
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Radiology, Weill Cornell Medical College, New York, New York
| | - Chaitanya B Medicherla
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Claudia L Ma
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York
| | | | - Nina Kukar
- Memorial Sloan Kettering Cancer Center, New York, New York
| | - Subhi Alaref
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York
| | - Raymond J Kim
- Duke Cardiovascular Magnetic Resonance Center, Durham, North Carolina
| | - Richard B Devereux
- Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York
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Mavrogeni SI, Sfikakis PP, Kitas GD, Kolovou G, Tektonidou MG. Cardiac involvement in antiphospholipid syndrome: The diagnostic role of noninvasive cardiac imaging. Semin Arthritis Rheum 2015; 45:611-6. [PMID: 26616201 DOI: 10.1016/j.semarthrit.2015.09.005] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2015] [Revised: 09/14/2015] [Accepted: 09/28/2015] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The antiphospholipid syndrome (APS) is an autoimmune disorder of acquired hypercoagulability characterized by vascular thrombosis, increased pregnancy morbidity, and elevated levels of antiphospholipid antibodies. Cardiac involvement in APS may be presented as heart valve disease affecting approximately a third of patients or less frequently as intracardial thombosis, pulmonary hypertension, right or left ventricular dysfunction, micro-vascular thrombosis, coronary artery, or micro-vascular disease with overt or silent clinical presentation. METHODS Noninvasive cardiovascular imaging plays a crucial role in the evaluation of heart involvement in APS. Transthoracic or transoesophageal echocardiography enable early, accurate diagnosis and severity assessment of HVD as well as of ventricular dysfunction and pulmonary hypertension. Studies by echocardiography and nuclear imaging have detected abnormalities in myocardial perfusion in approximately 30% of primary APS. CT scan is the technique of choice for the assessment of pulmonary embolism and can effectively detect intracardiac thrombi. Myocardial perfusion defects have been detected by 13N-ammonia PET in 40% of APS. Cardiovascular magnetic resonance (CMR) has identified an unexpectedly high prevalence of occult myocardial scarring and endomyocardial fibrosis in APS, and is the technique of choice, if quantification of heart valve disease and stress myocardial perfusion-fibrosis is needed. RESULTS Noninvasive, nonradiating imaging techniques, such as echocardiography and CMR are superior to CT or nuclear techniques and are of great value for the diagnosis and follow-up of both clinically overt and silent cardiac disease in APS. CONCLUSIONS The high incidence of cardiac involvement in APS demands early diagnosis/treatment and multimodality cardiovascular imaging is of great importance.
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Affiliation(s)
| | - Petros P Sfikakis
- First Department of Propeudeutic and Internal Medicine, Laikon Hospital, Athens University Medical School, Athens, Greece
| | - George D Kitas
- Arthritis Research UK Epidemiology Unit, Manchester University, Manchester, UK
| | | | - Maria G Tektonidou
- First Department of Internal Medicine, Rheumatology Unit, School of Medicine, University of Athens, Athens, Greece
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45
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Tang QY, Guo LD, Wang WX, Zhou W, Liu YN, Liu HY, Li L, Deng YB. Usefulness of contrast perfusion echocardiography for differential diagnosis of cardiac masses. ULTRASOUND IN MEDICINE & BIOLOGY 2015; 41:2382-2390. [PMID: 26087885 DOI: 10.1016/j.ultrasmedbio.2015.05.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Revised: 04/08/2015] [Accepted: 05/12/2015] [Indexed: 06/04/2023]
Abstract
The aim of this study was to assess the usefulness of contrast perfusion echocardiography in the differential diagnosis of different types of cardiac masses. Conventional echocardiography and contrast perfusion echocardiography were performed in 72 patients with cardiac masses. The degree of contrast enhancement of the mass and an adjacent section of myocardium after injection of contrast agent was determined by visual inspection and quantitative time-signal intensity curve analysis. The difference in maximal steady-state pixel intensity between the mass and the adjacent myocardium (ΔAmass-myocardium) was calculated. All masses had a pathologic diagnosis or resolved after anticoagulation. All 16 cardiac masses without enhancement on visual inspection were confirmed to be cardiac thrombi. Twenty-four masses with incomplete enhancement on visual inspection were recognized as benign tumors with validation methods. Of the 32 cardiac masses with complete enhancement, 30 were confirmed as malignant tumors and two as benign tumors with validation methods. The sensitivity and specificity of ΔAmass-myocardium in differentiating thrombi from tumors were 93% and 100%, respectively, and 100% and 97% in differentiating malignant tumors from benign tumors and thrombi. Both visual and quantitative assessment of degree of enhancement of cardiac masses in relation to the adjacent myocardium during contrast perfusion echocardiography had high diagnostic accuracy for differentiation of a thrombus from a tumor or a benign tumor from a malignant tumor.
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Affiliation(s)
- Qiao-Ying Tang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ling-Dan Guo
- Department of Medical Ultrasound, Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wen-Xuan Wang
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Wei Zhou
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ya-Ni Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hong-Yun Liu
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Li Li
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - You-Bin Deng
- Department of Medical Ultrasound, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
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46
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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: 3.4] [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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47
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Echocardiographic Evaluation of Coronary Artery Disease. Coron Artery Dis 2015. [DOI: 10.1007/978-1-4471-2828-1_10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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48
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Kharwar RB, Chandra S, Dwivedi SK, Saran RK. A pedunculated left ventricular thrombus in a women with peripartum cardiomyopathy: evaluation by three dimensional echocardiography. J Cardiovasc Ultrasound 2014; 22:139-43. [PMID: 25309691 PMCID: PMC4192412 DOI: 10.4250/jcu.2014.22.3.139] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2014] [Revised: 03/31/2014] [Accepted: 08/20/2014] [Indexed: 12/05/2022] Open
Abstract
Peripartum cardiomyopathy is a cardiac condition characterized by development of heart failure during the last month of pregnancy or during the first five months of post partum period without any other identifiable cause of heart failure. The hypercoagulable state in the pregnancy along with left ventricular (LV) systolic dysfunction predisposes the patient to thromboembolic complications like intraventricular thrombi. We report a case of a 30-year-old female with peripartum cardiomyopathy along with a highly mobile mass in the LV cavity on two dimensional echocardiography. Three dimensional transthoracic echocardiography clearly showed the pedicle of the mass attached to the interventricular septum along with internal echolucent areas within the mass. Due to denial of the patient to undergo surgery, she was started on oral anticoagulation, with complete dissolution of the mass within one month.
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Affiliation(s)
| | - Sharad Chandra
- Department of Cardiology, King Georges' Medical University, Lucknow, India
| | | | - Ram Kirti Saran
- Department of Cardiology, King Georges' Medical University, Lucknow, India
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49
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Abdelmoneim SS, Pellikka PA, Mulvagh SL. Contrast echocardiography for assessment of left ventricular thrombi. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2014; 33:1337-1344. [PMID: 25063398 DOI: 10.7863/ultra.33.8.1337] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
The diagnosis of intracardiac thrombi remains clinically relevant, with associated risks of systemic embolization and implications for antithrombotic management. Intravenously injected ultrasound contrast agents, composed of microbubbles smaller than red blood cells, have become established essential adjunctive tools for performance of state-of-the-art echocardiography, providing important information on cardiac structure and function. Despite advances in other imaging modalities, echocardiography remains the initial tool for diagnosis and risk stratification in patients predisposed to developing cardiac thrombi. Ultrasound contrast agents are approved for left ventricular (LV) opacification and endocardial border definition. Additionally, the use of contrast echocardiography facilitates LV thrombus detection by providing contrast opacification within the cardiac chambers to clearly show the "filling defect" of an intracardiac thrombus. Furthermore, contrast perfusion echocardiography can provide an assessment of the tissue characteristics of LV masses suspicious for intracardiac thrombi and, by differentiating an avascular thrombus from a tumor, results in improved diagnostic performance of echocardiography. This article presents a clinical vignette highlighting the sound judgment of using contrast echocardiography to aid in the diagnosis of LV thrombi and will review recent advances in imaging modalities for intracardiac thrombus detection.
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Affiliation(s)
- Sahar S Abdelmoneim
- Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota USA (S.S.A., P.A.P., S.L.M.); and Division of Cardiovascular Medicine, Assiut University, Assiut, Egypt (S.S.A.)
| | - Patricia A Pellikka
- Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota USA (S.S.A., P.A.P., S.L.M.); and Division of Cardiovascular Medicine, Assiut University, Assiut, Egypt (S.S.A.)
| | - Sharon L Mulvagh
- Mayo Clinic Cardiovascular Ultrasound Imaging and Hemodynamic Laboratory, Division of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota USA (S.S.A., P.A.P., S.L.M.); and Division of Cardiovascular Medicine, Assiut University, Assiut, Egypt (S.S.A.).
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50
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Tanaka D, Unai S, Diehl JT, Hirose H. Surgical removal of a large mobile left ventricular thrombus via left atriotomy. World J Clin Cases 2014; 2:32-35. [PMID: 24579068 PMCID: PMC3936216 DOI: 10.12998/wjcc.v2.i2.32] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2013] [Revised: 12/14/2013] [Accepted: 01/15/2014] [Indexed: 02/05/2023] Open
Abstract
Left ventricular (LV) thrombus is a life-threatening complication of severe LV dysfunction. Ventriculotomy has been a commonly performed procedure for LV thrombus; however, it often further decrease LV function after surgery. We present an alternative approach to thrombectomy in order to minimize the postoperative LV dysfunction. A 37-year-old female with a postpartum cardiomyopathy found to have poor LV function and a large left ventricular apical thrombus (3 cm × 3 cm) attached to the apex by a narrow stalk. Given her severe LV dysfunction, the LV thrombus was approached via left atriotomy under cardiopulmonary bypass. The LV thrombus was easily extracted with gentle traction via the mitral valve. Postoperatively, the patient was discharged home without any embolization event or inotropic support. LV thrombectomy via left atriotomy through the mitral valve could be an alternative option for the patients with poor LV function with a mobile LV thrombus.
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