Usefulness of contrast echocardiography for assessment of left ventricular thrombus after acute myocardial infarction

Multimodal Cardiac Imaging in the Assessment of Patients Who Have Suffered a Cardioembolic Stroke: A Review

Cardioembolic strokes account for 20-25% of all ischaemic strokes, with their incidence increasing with age. Cardiac imaging plays a crucial role in identifying cardioembolic causes of stroke, with early and accurate identification affecting treatment, preventing recurrence, and reducing stroke incidence. Echocardiography serves as the mainstay of cardiac evaluation. Transthoracic echocardiography (TTE) is the first line in the basic evaluation of structural heart disorders, valvular disease, vegetations, and intraventricular thrombus. It can be used to measure chamber size and systolic/diastolic function. Trans-oesophageal echocardiography (TOE) yields better results in identifying potential cardioembolic sources of stroke and should be strongly considered, especially if TTE does not yield adequate results. Cardiac computed tomography and cardiac magnetic resonance imaging provide better soft tissue characterisation, high-grade anatomical information, spatial and temporal visualisation, and image reconstruction in multiple planes, especially with contrast. These techniques are useful in cases of inconclusive echocardiograms and can be used to detect and characterise valvular lesions, thrombi, fibrosis, cardiomyopathies, and aortic plaques. Nuclear imaging is not routinely used, but it can be used to assess left-ventricular perfusion, function, and dimensions and may be useful in cases of infective endocarditis. Its use should be considered on a case-by-case basis. The accuracy of each imaging modality depends on the likely source of cardioembolism, and the choice of imaging approach should be tailored to individual patients.

[Extensive cardiac thombosis in a patient with disseminated intravascular coagulation]

Disseminated intravascular coagulation is a syndrome characterized by thrombin and fibrin generation which is associated with organ failure and death. Intracardiac thrombus may occur and further deteriorate prognosis. We report the case of a patient with massive intraventricular thrombus revealed by an acute ischemia of the upper left limb in a context of pulmonary adenocarcinoma complicated by a disseminated intravascular coagulation. We describe the diagnostic modalities and the fatal evolution.

What's the optimal duration of anticoagulation in patients with left ventricular thrombus?

INTRODUCTION

Left ventricular thrombus (LVT) occurs in acute myocardial infarction and in ischemic and non-ischemic cardiomyopathies. LVT may result in embolic stroke. Currently, the duration of anticoagulation for LVT is unclear. This is an important clinical question as prolonged anticoagulation is associated with increased bleeding risks, while premature discontinuation may result in embolic complications.

AREAS COVERED

There are no randomized trial data regarding anticoagulation duration for LVT. Guidelines and expert consensus recommend anticoagulation for 3-6 months with cessation of anticoagulation if interval imaging demonstrates thrombus resolution. Cardiac magnetic resonance imaging (CMR) is more sensitive and specific compared to echocardiography for LVT detection, and may be appropriate for high-risk patients. Prolonged anticoagulation may be considered in unresolved protuberant or mobile LVT, and in patients with resolved LVT but persistent depressed left ventricular ejection fraction and/or myocardial akinesia or dyskinesia.

EXPERT OPINION

CMR will likely be increasingly used for LVT surveillance to guide anticoagulation duration. Further research is needed to determine which patients with persistent LVT on CMR benefit from prolonged anticoagulation.

Effect of direct oral anticoagulants versus vitamin K antagonists or warfarin in patients with left ventricular thrombus outcomes: A systematic review and meta-analysis

INTRODUCTION

Left ventricular thrombus commonly occurs as a complication of acute anterior myocardial infarction and nonischemic cardiomyopathies with severe left ventricular systolic dysfunction. Its frequency is still high despite medical advances. Current guidelines recommend the use of vitamin k antagonists as first-line therapy, however, the off-label use of direct oral anticoagulants is becoming more frequent and attractive, given the better pharmacological and clinical profile, with the improvement of the patient's quality of life.

AIM

To provide an update on the currently existing evidence regarding the outcomes of efficacy and safety of direct oral anticoagulants (DOACs) as first-line therapy in left ventricular thrombus, in comparison to vitamin K antagonists (VKAs).

METHODS

A systematic review and meta-analysis of studies on the effects of direct oral anticoagulants versus vitamin K antagonists on left ventricular thrombi and on the results was performed.

RESULTS

Fourteen studies were included in the meta-analysis, with a total of 2498 patients (n=631 direct oral anticoagulants and n=1867 for VKAs). No significant differences were found in efficacy and safety outcomes (odds ratio (OR) 0.86; 95% confidence interval (CI), 0.55-1.33; p=0.50; I²=32%) and (OR 1.0; 95% CI, 0.78-1.30; p=0.93; I²=2%) respectively. No difference was noted in all-cause mortality (OR 0.92; 95% CI, 0.58-1.45; p=0.74; I²=0%). Thrombus resolution was observed in 288/416 in direct oral anticoagulants vs. 732/1085 patients treated with VKAs (OR 1.14; 95% CI, 0.77-1.66; p=0.50; I²=33%).

CONCLUSIONS

The findings of this meta-analysis suggest the potential utility of DOACs as a first-line strategy in patients with left ventricular thrombus.

The incidence of stroke in patients with early echocardiography after acute myocardial infarction

Left ventricular (LV) thrombus formation after ST-elevation myocardial infarction (STEMI) increases the risk of stroke. In our center, most echocardiograms are performed within 2 days post-STEMI. However, LV thrombi often become visible later. We assessed the 1-year incidence of stroke in patients without LV thrombus on echocardiography performed early (1-2 days) vs. later (day ≥ 3) post-STEMI. This retrospective observational study included 416 patients with acute STEMI. Patients with atrial fibrillation were excluded. All patients underwent echocardiography during admission. Patients with stroke within 12 months post-STEMI were identified from the hospital charts and administrative databases. Most echocardiograms (75%) were performed ≤ 2 days post-STEMI. LV thrombus was identified in 12 patients. One (8.3%) patient with LV thrombus and 10 (2.5%) patients without LV thrombus suffered stroke within 12 months post-STEMI. Most patients with stroke had apical akinesis. Most strokes occurred during the index admission or within 67 days of STEMI. There was no significant difference in the incidence of stroke between the patients with early vs. later echocardiography post-STEMI. The incidence of stroke after STEMI is low and similar between patients with echocardiography performed early vs. later post-STEMI which supports our current clinical practice. Importantly, most strokes occur in patients without LV thrombus on early echocardiography. High reported mortality rate associated with stroke following STEMI justifies the need for further validation in prospective studies to identify patients who may benefit from repeat imaging to detect later LV thrombus formation, and how this will impact patient outcomes and healthcare costs.

Validity of echocardiography for detection of left ventricular thrombus with surgical validation in patients awaiting durable left ventricular assist device

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.

Routine Screening with Contrast Echocardiography in Apical Infarctions? A case report

A a 80-year-old male underwent routine transthoracic echocardiography the day after primary percutaneous revascularization procedure for ST-elevation myocardial infarction. When ultrasound contrast  was injected, regular contrast-enhancement of the left ventricle (LV) excluded the presence of thrombus. A second echocardiogram, performed four months later, showed a hyperechoic image in the LV apex, which was confirmed after contrast injection as a thrombus. Four weeks later, a third follow-up echocardiogram appears apparently normal. However, contrast injection clearly demonstrates a new apex thrombus, in a slightly different location from the one detected previously. Standard echocardiography is often inconclusive or falsely negative regarding the detection of apical thrombus. Maybe the time has come for routine contrast-echo screening in post-myocardial infarction patients with the high likelihood of thrombus, such as in cases of apical infarction, even if the standard echocardiogram appears unremarkable.

Multi-Modality Imaging for the Identification of Arrhythmogenic Substrates Prior to Electrophysiology Studies

Noninvasive cardiac imaging is crucial for the characterization of patients who are candidates for cardiac ablations, for both procedure planning and long-term management. Multimodality cardiac imaging can provide not only anatomical parameters but even more importantly functional information that may allow a better risk stratification of cardiac patients. Moreover, fusion of anatomical and functional data derived from noninvasive cardiac imaging with the results of endocavitary mapping may possibly allow a better identification of the ablation substrate and also avoid peri-procedural complications. As a result, imaging-guided electrophysiological procedures are associated with an improved outcome than traditional ablation procedures, with a consistently lower recurrence rate.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

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.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

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.

Imaging in patients with suspected acute heart failure: timeline approach position statement on behalf of the Heart Failure Association of the European Society of Cardiology

Acute heart failure is one of the main diagnostic and therapeutic challenges in clinical practice due to a non-specific clinical manifestation and the urgent need for timely and tailored management at the same time. In this position statement, the Heart Failure Association aims to systematize the use of various imaging methods in accordance with the timeline of acute heart failure care proposed in the recent guidelines of the European Society of Cardiology. During the first hours of admission the point-of-care focused cardiac and lung ultrasound examination is an invaluable tool for rapid differential diagnosis of acute dyspnoea, which is highly feasible and relatively easy to learn. Several portable and stationary imaging modalities are being increasingly used for the evaluation of cardiac structure and function, haemodynamic and volume status, precipitating myocardial ischaemia or valvular abnormalities, and systemic and pulmonary congestion. This paper emphasizes the central role of the full echocardiographic examination in the identification of heart failure aetiology, severity of cardiac dysfunction, indications for specific heart failure therapy, and risk stratification. Correct evaluation of cardiac filling pressures and accurate prognostication may help to prevent unscheduled short-term readmission. Alternative advanced imaging modalities should be considered to assist patient management in the pre- and post-discharge phase, including cardiac magnetic resonance, computed tomography, nuclear studies, and coronary angiography. The Heart Failure Association addresses this paper to the wide spectrum of acute care and heart failure specialists, highlighting the value of all available imaging techniques at specific stages and in common clinical scenarios of acute heart failure.

2019 HRS/EHRA/APHRS/LAHRS expert consensus statement on catheter ablation of ventricular arrhythmias

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.

Echocardiographic measures associated with the presence of left ventricular thrombus in patients with chemotherapy-related cardiac dysfunction

BACKGROUND

Previous studies have not evaluated the prevalence and specific risk factors for the development of left ventricular (LV) thrombus in patients with severely reduced left ventricular dysfunction due to chemotherapy-related cardiomyopathy. We sought to evaluate the prevalence and potential markers of LV thrombus in this patient population.

METHODS

From January 2009 to December 2013, patients with chemotherapy-related severe LV dysfunction (LV ejection fraction [LVEF] ≤ 30%) identified from MD Anderson Cancer Center database were reviewed. Patient characteristics and echocardiographic parameters were analyzed to determine potential risk factors for LV thrombus.

RESULTS

A total of 121 patients met inclusion criteria (age 54.8 ± 15.2 years; female 63.6%; LVEF 26.3 ± 4%). LV thrombus was present in 9 patients (7.4%). Patients with LV thrombus have significantly lower LVEF compared to those without (18.7 ± 3.8% vs 26.9 ± 3.4%, P < .0001). Prevalence of LV thrombus increased as LVEF decreased and was the highest in patients with LVEF < 20%. By univariate analysis, decreased LVEF, particularly LVEF < 20% (OR 36.30, 95% CI 7.35-179.25, P < .0001) and restrictive LV filling pattern (OR 18.13, 95% CI 4.17-78.89, P = .0001) were associated with presence of LV thrombus.

CONCLUSION

In patients with severely reduced LV systolic function due to chemotherapy-induced cardiomyopathy, LV thrombus was found in 7.4% of subjects. Severely decreased LVEF (<20%) and restrictive LV filling pattern were associated with the presence of LV thrombus.

Clinical practice of contrast echocardiography: recommendation by the European Association of Cardiovascular Imaging (EACVI) 2017

Contrast echocardiography is widely used in cardiology. It is applied to improve image quality, reader confidence and reproducibility both for assessing left ventricular (LV) structure and function at rest and for assessing global and regional function in stress echocardiography. The use of contrast in echocardiography has now extended beyond cardiac structure and function assessment to evaluation of perfusion both of the myocardium and of the intracardiac structures. Safety of contrast agents have now been addressed in large patient population and these studies clearly established its excellent safety profile. This document, based on clinical trials, randomized and multicentre studies and published clinical experience, has established clear recommendations for the use of contrast in various clinical conditions with evidence-based protocols.

Usefulness and Cost-Effectiveness of Universal Echocardiographic Contrast to Detect Left Ventricular Thrombus in Patients with Heart Failure and Reduced Ejection Fraction

Contrast is a recommended but frequently unused tool in transthoracic echocardiography to improve detection of left ventricular thrombus in patients with ejection fraction (EF) ≤35%. The clinical and economic outcomes of a possible solution (i.e., universal contrast use) remain uncertain. To estimate clinical benefit, cost, and cost-effectiveness of a diagnostic strategy of universal use of contrast (vs no contrast) during echocardiography in patients with reduced EF, we created a decision analytic model using echocardiography sensitivity and specificity for left ventricular thrombus detection from a meta-analysis, as well as survival and cost estimates from published literature. Universal contrast use (vs nonuse) did not result in clinical or statistical improvement in estimated life years (8.509 vs 8.504) or quality-adjusted life years (5.620 vs 5.616). The cost of contrast was offset by reductions in subsequent health-care costs, resulting in similar total costs ($201,569 vs $201,573). In conclusion, although an intuitively attractive practice improvement strategy, universal contrast use strategy appears to offer no appreciable benefit to quality-adjusted survival or financial outcomes in patients with low EF.

Standardization of Impella®-assisted patient management

The presence of high-risk features on candidates to percutaneous revascularization is increasingly leading to Impella®-assisted procedures (IAPs). While IAPs are safe and effective procedures, they still require managing a degree of complexity. Clinicians often rely on their ability to recall every step of operative procedures. However, during stressful situations, levels of cognitive function are compromised leading to planning and execution failures and decreased safety. Many high-risk activities such as aviation, aerospace industry, and nuclear plants have been using protocols, standardized procedures and checklists for many years. The purpose of the present article is to make a proposal for the standardization of ordinary medical activities required outside the Cath Lab for the management of patients before and after IAPs.

Comparison of the usefulness of enoxaparin versus warfarin for prevention of left ventricular mural thrombus after anterior wall acute myocardial infarction

Left ventricular (LV) thrombus is one of the most common complications in patients with anterior acute myocardial infarction (AMI) and LV dysfunction. Although anticoagulation is frequently prescribed, data regarding the appropriate drug, duration, risks, and effect on echocardiographic indices of thrombus are lacking. Moreover, given the difficulty in obtaining adequate anticoagulation with warfarin, it is possible that short-term treatment with a more predictable agent would be effective. We randomized 60 patients at high risk of developing LV mural thrombus (anterior acute myocardial infarction with Q waves and ejection fraction≤40%) to receive either enoxaparin 1 mg/kg (maximum 100 mg) subcutaneously every 12 hours for 30 days or traditional anticoagulation (intravenous heparin followed by oral warfarin for 3 months). Clinical evaluations and transthoracic echocardiograms were obtained at baseline, in-hospital, and at 3.5 months. There were no differences between the groups regarding baseline demographics, acute echocardiographic findings, and in-hospital outcomes. The length of hospital stay tended to be shorter for the enoxaparin group (4.6 vs 5.6; p=0.066) and the corresponding hospital costs ($25,837 vs $34,666; p=0.18). At 3 months, bleeding and thromboembolic events were rare and similar between enoxaparin and warfarin groups. Although more patients had probable mural thrombus in the enoxaparin group compared with warfarin at 3.5 months (15% vs 4%; p=0.35), this was not significantly different. In conclusion, the use of enoxaparin tends to shorten hospitalization and lower cost of care. However, at 3.5 months, there appears to be numerically higher (but statistically insignificant) rates of LV thrombus in the enoxaparin group.

The use of echocardiography in acute cardiovascular care: Recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

The use of echocardiography in acute cardiovascular care: recommendations of the European Association of Cardiovascular Imaging and the Acute Cardiovascular Care Association

Echocardiography is one of the most powerful diagnostic and monitoring tools available to the modern emergency/ critical care practitioner. Currently, there is a lack of specific European Association of Cardiovascular Imaging/Acute Cardiovascular Care Association recommendations for the use of echocardiography in acute cardiovascular care. In this document, we describe the practical applications of echocardiography in patients with acute cardiac conditions, in particular with acute chest pain, acute heart failure, suspected cardiac tamponade, complications of myocardial infarction, acute valvular heart disease including endocarditis, acute disease of the ascending aorta and post-intervention complications. Specific issues regarding echocardiography in other acute cardiovascular care scenarios are also described.

Contrast echocardiography for assessment of left ventricular thrombi

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.

Incidence and predictors of early left ventricular thrombus after ST-elevation myocardial infarction in the contemporary era of primary percutaneous coronary intervention

The aim of this study was to define the incidence of left ventricular thrombus (LVT) and its predictors in the contemporary era of primary percutaneous intervention (pPCI) and contrast echocardiography. We retrospectively analyzed 1,059 patients presenting with ST-elevation myocardial infarction (STEMI) to our tertiary cardiac center and treated with pPCI. Preprocedural pharmacology and procedural technique (including access route, the use of drug-eluting stents, and thrombectomy) were at the operators' discretion. Transthoracic echocardiography was performed before discharge; echo contrast agent was used when appropriate. LVT was detected in 42 subjects (4%). There were no significant differences in baseline demographics or pre-PCI clinical features between the 2 groups. Post-treatment, mean ejection fraction (EF) in patients with LVT was 35±8.4% and in those without LVT was 47±10%, p<0.001. Thirty-seven patients (88%) in the LVT group presented with an anterior STEMI versus 471 patients (42%) in the without LVT group (p<0.001). Apical akinesis was noted in all patients with LVT irrespective of the principal location of the MI. Multivariate analysis predictors of LVT were reduced EF, anterior site of MI, and the use of platelet glycoprotein IIb/IIIa inhibitors. After diagnosis of LVT, patients were treated with warfarin for 3 to 6 months. No significant difference in mortality was detectable at discharge between the 2 groups. In conclusion, in the contemporary era of pPCI, the incidence of LVT in patients with STEMI is significantly lower than that of the previous (thrombolysis) literature. The early presence of LVT is more likely in patients with anterior STEMI (involving the apex) and reduced EF.

Prevalence and Aetiology of Left Ventricular Thrombus in Patients Undergoing Transthoracic Echocardiography at the University of Maiduguri Teaching Hospital

Objectives. We sought to determine the prevalence and aetiology of LVT among patients undergoing echocardiography. Methods. We reviewed case notes and echocardiographic data of patient diagnosed with LVT using noncontrast transthoracic echocardiography. Definition of various conditions was made using standard guidelines. Mean ± SD were derived for continuous variables and comparison was made using Student's t-test. Results. Total of 1302 transthoracic echocardiograms were performed out of which 949 adult echocardiograms were considered eligible. Mean age of all subjects with abnormal echocardiograms was 44.73 (16.73) years. Abnormalities associated with LVT were observed in 782/949 (82.40%) subjects among whom 84/782 (8.85%) had LVT. The highest prevalence of 39.29% (33/84) was observed in patients with dilated cardiomyopathy, followed by myocardial infarction with a prevalence of 29.76% (25/84). Peripartum cardiomyopathy accounted for 18/84 (21.43%) cases with some having multiple thrombi, whereas hypertensive heart disease was responsible for 6/84 (7.14%) cases. The lowest prevalence of 2.38% (2/84) was observed in those with rheumatic heart disease. Left ventricular EF of <35% was recorded in 55/84 (65.48%). Conclusions. Left ventricular thrombus is common among patients undergoing echo, with dilated cardiomyopathy being the most common underlying aetiology followed by myocardial infarction. Multiple LVTs were documented in peripartum cardiomyopathy.

Use of contrast echocardiography in intensive care and at the emergency room

Bedside echocardiography in emergency room (ER) or in intensive care unit (ICU) is an important tool for managing critically ill patients, to obtain a timely accurate diagnosis and to immediately stratify the risk to the patient’s life. It may also render invasive monitoring unnecessary. In these patients, contrast echocardiography may improve quality of imaging and also may provide additional information, especially regarding myocardial perfusion in those with suspected coronary artery disease. This article focuses on the principle of contrast echocardiography and the clinical information that can be obtained according to the most frequent presentations in ER and ICU.

Left ventricular thrombus in patients with acute myocardial infarction:Case report and Caribbean focused update

Despite the well documented benefit of echocardiography in acute coronary syndromes, its wide-scale use in the Caribbean is limited by access, health literacy and affordability. Because of the limited use of echocardiography in the region, routine complications of acute myocardial infarction (AMI) are not fully appreciated and may go unrecognized, further contributing to increased cardiovascular morbidity and mortality. It is therefore necessary to bring focus to this common clinical condition and highlight the clinical utility of echocardiography in facilitating timely and accurate diagnosis. We report here a case of large left ventricular (LV) thrombus in a patient with AMI. Coronary angiography showed completely occluded left anterior descending artery (LAD) with angiographically normal remaining vessels. Immediate anticoagulation was commenced with heparin and overlapped with warfarin. No Primary Angioplasty (PA) was done based on the evidence from occluded artery trial. LV thrombus was completely resolved on echocardiography at three months. No evidence of thrombo-embolism was found during the resolution of LV thrombus.

Prevalence of coronary artery spasm during dobutamine stress echocardiography

The aim of this study was to assess the prevalence of coronary artery spasm during dobutamine stress echocardiography (DSE). Over a 9-year period (from November 2001 to October 2010) we reviewed all patients (n = 2,224) referred for DSE. Criteria for selection included patients > 18 years old who underwent DSE. We systematically analyzed all electrocardiograms obtained during DSE to detect ST-segment elevation during the examination. All patients with ST-segment elevation underwent coronary angiography. DSE was performed in 2,179 patients. ST-segment elevation was observed in 21 patients, all of whom underwent emergency coronary angiography. In 13 of these 21 patients (62%) significant coronary stenosis was observed: 6 patients with critical coronary stenosis and 7 patients with chronic coronary occlusion. The remaining 8 patients (38% of patients presenting with ST-segment elevation during DSE, 7 men, mean age 67 ± 11 years) had no significant coronary stenosis. Prevalence of coronary artery spasm during DSE was 0.4%. In conclusion, physicians should be aware that, although rare, coronary artery spasm may occur during DSE.

LV thrombus detection by routine echocardiography: insights into performance characteristics using delayed enhancement CMR

OBJECTIVES

This study sought to evaluate performance characteristics of routine echo for left ventricular thrombus (LVT).

BACKGROUND

Although the utility of dedicated echocardiography (echo) for LVT is established, echo is widely used as a general test for which LVT is rarely the primary indication. We used delayed-enhancement cardiac magnetic resonance (DE-CMR) as a reference to evaluate LVT detection by routine echo.

METHODS

Dedicated LVT assessment using DE-CMR was prospectively performed in patients with left ventricular systolic dysfunction. Echoes were done as part of routine clinical care. Echo and CMR were independently read for LVT and related indexes of LVT size, shape, and image quality/diagnostic confidence. Follow-up was done for embolic events and pathology validation of LVT.

RESULTS

In this study, 243 patients had routine clinical echo and dedicated CMR within 1 week without intervening events. Follow-up supported DE-CMR as a reference standard, with >5-fold difference in endpoints between patients with versus without LVT by DE-CMR (p = 0.02). LVT prevalence was 10% by DE-CMR. Echo contrast was used in 4% of patients. Echo sensitivity and specificity were 33% and 91%, with positive and negative predictive values of 29% and 93%. Among patients with possible LVT as the clinical indication for echo, sensitivity and positive predictive value were markedly higher (60%, 75%). Regarding sensitivity, echo performance related to LVT morphology and mirrored cine-CMR, with protuberant thrombus typically missed when small (p ≤ 0.02). There was also a strong trend to miss mural thrombus irrespective of size (p = 0.06). Concerning positive predictive value, echo performance related to image quality, with lower diagnostic confidence scores for echoes read positive for LVT in discordance with DE-CMR compared with echoes concordant with DE-CMR (p < 0.02).

CONCLUSIONS

Routine echo with rare contrast use can yield misleading results concerning LVT. Echo performance is improved when large protuberant thrombus is present and when the clinical indication is specifically for LVT assessment.

Contrast echocardiography: what have we learned from the new guidelines?

A new consensus statement on the clinical applications of ultrasound contrast agents was published in November 2008 in the Journal of the American Society of Echocardiography. These guidelines provide the rationale for contrast use, and specifically highlight a number of clinical scenarios in which contrast should always be considered. These include the 1) assessment of left ventricular (LV) systolic function--especially when quantitative LV volumes and ejection fraction, or serial assessments are required, and during stress echocardiography; 2) evaluation of the LV apex; 3) evaluation of mechanical complications of myocardial infarction; 4) evaluation of suspected intracardiac mass; and 5) to enhance Doppler signals in the systemic circulation. Furthermore, detailed outlines on contrast administration, logistics, personnel requirements, and responsibilities are provided. Recent data published in the past 2 years to support these recommendations, and contrast agent safety data, are reviewed in this article.

Diagnostic value of contrast echocardiography in Tako-Tsubo cardiomyopathy

BACKGROUND

Tako-Tsubo cardiomyopathy is a clinical entity mimicking acute coronary syndrome. Assessment of left ventricular function may be difficult using conventional echocardiography.

AIMS

to characterize left ventricular systolic function using contrast echocardiography in Tako-Tsubo cardiomyopathy.

METHODS

We prospectively studied 63 consecutive women admitted for suspected acute coronary syndrome who underwent coronary arteriography, biplane left ventricular angiography and conventional and contrast echocardiography; 25 women had Tako-Tsubo cardiomyopathy (group 1), 25 women had proven coronary artery disease (group 2) and 13 women had no significant coronary lesion (group 3). Echocardiographic interpretation was performed by two observers: a physician trainee (observer 1) and an experienced investigator (observer 2).

RESULTS

Left ventricular segments were assessed for wall motion abnormalities, which were present in 70 and 88% (observer 1) and in 91 and 99% (observer 2), using conventional and contrast echocardiography, respectively (P<0.0001). Accuracy for the diagnosis of Tako-Tsubo cardiomyopathy was improved significantly for both observers using contrast echocardiography: for observer 1, sensitivity was 56 and 88%, respectively, using conventional and contrast echocardiography (P=0.01), whereas for observer 2, sensitivity was 72 and 96%, respectively (P=0.04). Interobserver agreement was excellent using contrast agent (kappa=0.85 vs 0.34 using conventional echocardiography). The blinded review of left ventriculograms distinguished Tako-Tsubo cardiomyopathy from coronary artery disease correctly in 96% of cases.

CONCLUSIONS

Contrast echocardiography could be used in routine practice to replace left ventricular angiography in Tako-Tsubo cardiomyopathy.