Cardiac Imaging for Assessment of Left Ventricular Thrombus

Jason S Chinitz, Dorinna D Mendoza, Raymond J Kim, Jonathan W Weinsaft
US Cardiology, 2009;6(2):27-33
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Abstract

Accurate detection of left ventricular (LV) thrombus is important, as thrombus provides a substrate for thromboembolic events and a rationale for anticoagulation. Non-contrast echocardiography (echo) detects LV thrombus based on anatomical appearance. This approach can be straightforward when thrombus is large in size and protuberant in shape, but challenging when thrombus is small or mural. While thrombi can vary in size and shape, it can be intrinsically defined based on avascular tissue composition. Contrast-enhanced imaging can be used to facilitate anatomical and tissue characterization approaches for thrombus detection. Contrast echo, which identifies thrombus based on anatomical appearance, provides improved thrombus detection versus non-contrast echo. Both perfusion echo and delayed-enhancement magnetic resonance imaging (MRI) assess thrombus based on tissue characteristics and improve diagnostic performance compared with MRI or echo approaches that assess thrombus based on anatomical appearance. Tissue characterization is particularly advantageous for detection of small or mural thrombus. This article reviews the role of cardiac imaging for LV thrombus, with a focus on recent advances in thrombus detection as provided by contrast-enhanced imaging.
Keywords
Left ventricular thrombus, echocardiography, magnetic resonance imaging, contrast
Disclosure Jonathan W Weinsaft, MD, is the recipient of a research grant from Lantheus Medical Imaging (echo contrast manufacturer). The remaining authors have no conflicts of interest to declare.
Received: August 27, 2009 Accepted September 22, 2009
Correspondence: Jonathan W Weinsaft, MD, Assistant Professor of Medicine, Greenberg Division of Cardiology, Weill Medical College of Cornell University, 525 East 68th Street, Starr-4, New York, NY 10021. E: jww2001@med.cornell.edu

Accurate detection of left ventricular (LV) thrombus affects clinical outcomes and therapeutic management, as thrombus provides a substrate for thromboembolic events and a rationale for anticoagulation. Relative risk (RR) for thrombus development is highest among subjects with systolic heart failure or myocardial infarction (MI), reflecting a link between impaired LV blood stasis, pro-coagulant mediators, and thrombosis. As the prevalence of heart failure and coronary artery disease (CAD) continues to increase, the clinical importance of accurate diagnostic imaging for thrombus is heightened.

Non-contrast echocardiography (echo) is widely used to detect thrombus based on its anatomical appearance. This imaging approach is effective when thrombus is large in size or protuberant (intracavitary) in shape, but can be challenging when thrombus is small or flat (mural). Recent studies have reported that up to two-thirds of LV thrombi can be missed by routine non-contrast echo, with mural or small thrombi least likely to be detected.1–4 These limitations have spurred the use of contrast-enhanced imaging for improved thrombus detection. Two major imaging approaches have been used for this purpose: contrast can be used to opacify the LV cavity and thereby facilitate detection of thrombus based on anatomical appearance; alternatively, contrast can be used to identify thrombus based on tissue characteristics. Each of these contrast-enhanced imaging approaches has been shown to provide incremental value over non-contrast echo for detection of LV thrombus.

This article reviews the role of cardiac imaging for LV thrombus, with a focus on recent improvements in thrombus detection as provided by contrast-enhanced imaging.

Definition of Left Ventricular Thrombus
Anatomical Criteria

Thrombus has traditionally been identified based on its anatomical appearance (see Figure 1A). Echo studies have generally defined thrombus as a mass within the LV cavity with margins distinct from ventricular endocardium and distinguishable from papillary muscles, chordae, trabeculations, or technical artifacts.5,6 Additional features, such as pattern of mobility,7 size,8 and associated ventricular wall motion abnormalities,9–13 have each been used as adjuvant diagnostic criteria for thrombus.

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