Uncommon intraventricular thrombus formation between the posterior mitral leaflet and the lateral left ventricular wall
1 Department of Cardiology and Angiology, Marienhospital Herne, Ruhr University Bochum, D-44625 Herne, Germany
2 Department of Cardiology, Heart and Diabetes Center North Rhine—Westphalia, Ruhr University Bochum, Georgstrasse 11, D-32545 Bad Oeynhausen, Germany
3 Institute of Radiology, Nuclear Medicine and Molecular Imaging, Heart and Diabetes Center North Rhine—Westphalia, Ruhr University Bochum, Bad Oeynhausen, Germany
Received 21 August 2007; accepted after revision 30 September 2007.
* Corresponding author. Tel: +49 2323 4990; fax: +49 2323 499-360. E-mail address: thomas.butz{at}marienhospital-herne.de
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Abstract |
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Transthoracic echocardiography demonstrated an intraventricular mass between the posterior mitral leaflet and the lateral left ventricular (LV) free wall in a 61-year-old man. Because of this uncommon localization an intracardial tumor, an endocarditis of the mitral valve or an intraventricular thrombus was suspected. Magnetic resonance imaging (MRI) ruled out an intracardial tumor and revealed a myocardial scarring of the LV free wall covered by an intraventricular thrombus by late gadolinium enhancement. MRI can distinguish subacute clots—which do not enhance after contrast material injection—from organized thrombi. The characterization of thrombi can be used to predict the risk of embolism, which is higher for subacute clots than for organized thrombi.
Keywords: Thrombus formation; Left ventricle; Echocardiography; Magnetic resonance imaging
Two-dimensional transthoracic echocardiography (TTE) and transoesophageal echocardiography (TEE) are the most commonly used techniques for the clinical identification and follow-up of intracardiac masses and left ventricular (LV) thrombi.
A 61-year old man presented with dyspnoea (NYHA class III) and chest pain. TTE demonstrated an intraventricular mass between the posterior mitral leaflet (PML) and the lateral LV free wall (Figure 1A and B; see Supplementary material online, Movie 1). Because of this uncommon localization an intracardiac tumour, an endocarditis of the mitral valve, or an intraventricular thrombus was suspected.
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MRI was performed for further diagnostic work-up (Figure 2; see Supplementary material online, Movie 2). An intracardiac tumour was ruled out by a MRI perfusion-analysis of the mass (Figure 3). Late gadolinium enhancement revealed a myocardial scarring of the LV free wall covered by an intraventricular thrombus (Figure 4).
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LV thrombi occur in at least 5% of patients after acute myocardial infarction (AMI) and adversely affect the prognosis of the patient. They are formed within 2 weeks after AMI, when inflammatory cells have infiltrated into the necrotic myocardium. Inflammatory changes on the endocardiac surface may induce platelet deposition and fibrin net formation through interaction with proinflammatory cytokines.1,2 It has been shown that a greater elevation of serum CRP level was associated with a higher incidence of LV thrombus after AMI, suggesting an important role of the inflammatory response in mural thrombus formation.1
MRI can distinguish subacute clots—which do not enhance after contrast material injection—from organized thrombi.3 Several studies demonstrated that MRI was more sensitive for the detection of LV thrombi than TTE and TEE.
The characterization of thrombi can be used to predict the risk of embolism, which is higher for subacute clots than for organized thrombi.3,4
Conflict of interest: none declared.
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Supplementary material |
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Supplementary material associated with this article can be found in the online version at www.ejechocard.oxfordjournals.org.
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References |
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- Anzai T, Yoshikawa T, Kaneko H, Maekawa Y, Iwanaga S, Asakura Y, et al. Association between serum C-reactive protein elevation and left ventricular thrombus formation after first anterior myocardial infarction. Chest (2004) 125:384–389.[CrossRef][Web of Science][Medline]
- Srichai MB, Junor C, Rodriguez LL, Stillman AE, Grimm RA, Lieber ML, et al. Clinical, imaging, and pathological characteristics of left ventricular thrombus: a comparison of contrast-enhanced magnetic resonance imaging, transthoracic echocardiography, and transesophageal echocardiography with surgical or pathological validation. Am Heart J (2006) 152:75–84.[CrossRef][Web of Science][Medline]
- Barkhausen J, Hunold P, Eggebrecht H, Schuler WO, Sabin GV, Erbel R, et al. Detection and characterization of intracardiac thrombi on MR imaging. Am J Roentgenol (2002) 179:1539–1544.
[Abstract/Free Full Text] - Rustemli A, Bhatti TK, Wolff SD. Evaluating cardiac sources of embolic stroke with MRI. Echocardiography (2007) 24:301–308.[CrossRef][Web of Science][Medline]
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