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 Table of Contents  
CASE REPORT
Year : 2022  |  Volume : 10  |  Issue : 1  |  Page : 56-59

Incidentally detected large ventricular thrombus on echocardiography: A case series


Department of Cardiology, Osmania General Hospital, Hyderabad, Telangana, India

Date of Submission05-Dec-2021
Date of Decision26-Dec-2021
Date of Acceptance27-Dec-2021
Date of Web Publication13-Apr-2022

Correspondence Address:
Dr. Srinivas Ravi
Department of Cardiology, Osmania General Hospital, Hyderabad - 500 012, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/heartindia.heartindia_102_21

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  Abstract 


Ventricular thrombus is a major risk factor for systemic thromboembolism. It complicates both acute and chronic phases of ischemic heart disease (IHD) and, less frequently, non-ischemic cardiomyopathies. However, ventricular thrombus does not always manifest with thromboembolism. Advances in technology, especially the echocardiography, have improved the detection rates of intracardiac thrombi. Regarding the management, there are several uncertainties to date. We present six varied cases with incidental detection of ventricular thrombus on echocardiography with no clinically evident embolism at admission. Of the six cases, three patients had embolic complications after initiation of systemic anticoagulation.

Keywords: Echocardiography, ischemic cardiomyopathy, thromboembolism, ventricular thrombus


How to cite this article:
Parvathareddy KM, Maale SR, Nagula P, Ravi S. Incidentally detected large ventricular thrombus on echocardiography: A case series. Heart India 2022;10:56-9

How to cite this URL:
Parvathareddy KM, Maale SR, Nagula P, Ravi S. Incidentally detected large ventricular thrombus on echocardiography: A case series. Heart India [serial online] 2022 [cited 2022 May 16];10:56-9. Available from: https://www.heartindia.net/text.asp?2022/10/1/56/343065




  Introduction Top


Ventricular thrombus is a serious complication of ischemic heart disease, particularly acute myocardial infarction and various nonischemic cardiomyopathies.[1],[2] Early detection and management are required to prevent serious complications of embolism such as stroke, pulmonary embolism, and mesenteric ischemia. We present six cases of large ventricular thrombus incidentally diagnosed on echocardiography along with the review of the literature.


  Cases Report Top


The clinical profile of six cases is presented in [Table 1]. All the patients were referred to the cardiology department, and the echocardiography was done given the history of the cardiac disorder (Case 1, 2, 3, and 5) or as part of an evaluation of dyspnea (Case 4, 6). None had an embolic event before the echocardiographic diagnosis. Two cases had prior ischemic heart disease (Case 1, 3). All the cases had dilated chambers and severe ventricular dysfunction on echocardiography. The largest thrombus was seen in (Case 1) occupying half of the left ventricle with multiple vacuolations. Three patients died after the initiation of anticoagulation (Case 1, 4, and 5). Three patients had a regression in size of thrombus and had no embolic event (Case 2, 3, and 6). The patients with regression of thrombus size were kept on oral anticoagulants (OAC) (either Warfarin or Rivaroxaban). [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6] represent the echocardiographic pictures of Case 1, 2, 3, 4, 5, and 6 respectively.
Table 1: Clinical Profile, echocardiographic features and hospital course of the cases with ventricular thrombus

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Figure 1: Transthoracic echocardiogram apical four chamber view showing giant left ventricular thrombus occupying half of the cavity

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Figure 2: Transthoracic echocardiogram apical four chamber view showing the left ventricle apex filled with thrombus

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Figure 3: Transthoracic echocardiogram apical four chamber view showing thrombus attached to the lateral aspect of the left ventricle

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Figure 4: Transthoracic echocardiogram apical four chamber view showing (a) left and (b) right ventricular thrombus

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Figure 5: Transthoracic echocardiogram apical four chamber view showing (a) left and (b) right ventricular thrombus attached to the septum

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Figure 6: Transthoracic echocardiogram apical four chamber view showing ventricular thrombus attached to the left ventricular apex and septum

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  Discussion Top


Thrombi represent the most frequently found intracardiac masses.[3] Ventricular thrombus is a serious complication of acute myocardial infarction; however, it is also seen in a wide variety of nonischemic cardiac disorders.[1],[2],[3] Acute myocardial infarction leading to regional wall motion abnormality, ventricular dysfunction, and stasis of blood (Virchow's triad) will result in thrombus formation.[3] In nonischemic etiologies, the presence of dilated chambers, severe ventricular dysfunction, and blood stasis lead to the thrombus formation.[3]

Epidemiological studies reveal that the incidence of ventricular thrombus (left ventricular [LV] thrombus) has been decreased from 30% to 46% in the prepercutaneous coronary intervention era to 5%–10% in the present era.[4],[5] Right ventricular (RV) thrombus usually originates from systemic venous or tumor thrombosis and is rarely secondary to an inferior wall with infarction of RV apex.[6] The usual location of the thrombus is the apex and the interventricular septum.[7] In our case series, the thrombus was located at the apex in four cases (Case 1, 2, 4, and 6), had a septal attachment in one (Case 5), and in the lateral aspect of LV in one (Case 3).

Echocardiography is the primary imaging modality in the detection of cardiac thrombi with a specificity of 85%–90% and sensitivity of 95%.[4] However, close mimickers like false tendon, trabeculae, and reverberation artifacts can lead to a false diagnosis. Intravenous echo contrast may improve the diagnosis. Cardiac magnetic resonance imaging with contrast (delayed enhancement) has better accuracy, less intra and interobserver variability when compared to transthoracic echocardiography.[3] with an added advantage of differentiation of acute and chronic thrombus.[3]

The serious complication of untreated ventricular thrombi is Embolism. The emboli manifestations vary based on the location of the thrombus. Systemic emboli (stroke, end-organ infarcts) are seen with the left ventricle, whereas pulmonary emboli and infarct with the right ventricle.[8] The mobile thrombi, protruding into the cavity, with larger area,[3] having central echolucency,[3] and hyperkinesia of the adjacent myocardial segments have increased tendency for embolism. Apart from the features of thrombus a history of embolization in the past, severe systolic dysfunction, dilated chambers, atrial fibrillation, and advanced patient age also increase the tendency for embolism.[9] In Case 1, the patient is elderly with a giant LV thrombus, protruding into the LV cavity and multiple vacuolations, which is in favor of embolism. Similarly, in Case 4 and 5, the thrombi were large and mobile favoring an embolic event. In Case 2, 3, and 6 the course was uneventful, and the thrombi were relatively small in size, uniform in echotexture, and had a wide base with adherence to the underlying structure.

Several uncertainties remain regarding the optimal treatment strategy of the Ventricular thrombus. The guidelines suggest the use of OAC Vitamin K antagonists as first-line therapy, immediately after the diagnosis.[10] Bridging with parenteral anticoagulation should be discontinued when an effective therapeutic range with warfarin has been achieved. Although anticoagulation is given as secondary prophylaxis to prevent an embolism, embolic events do occur after initiation of anticoagulation (three cases in our series).

Echocardiography at 3 months is recommended to see for the resolution of thrombus. In patients with contraindications for anticoagulation, a close follow-up of 1–2 weeks is recommended. Long term anticoagulation is required if there is no resolution or having a recurrence of embolism at follow up. Experts suggest that if the thrombus has organized, anticoagulation can be stopped as the potential to embolism decreases on endothelialization of the thrombus.[10] The use of thrombolytic drugs in the management of thrombus is controversial.[10] Giant LV thrombi and associated ventricular aneurysms should be managed by surgery rather than anticoagulation alone.[10] Early detection of the wall motion abnormalities, optimizing the medications will decrease the occurrence of thrombi.


  Conclusion Top


Ventricular thrombus complicates both ischemic and nonischaemic cardiomyopathies. The diagnosis is usually after an index event or evaluation of an embolic event; however, they can be incidentally detected on imaging. Immediate initiation of anticoagulation with a serial follow-up for regression in thrombus size is recommended. Despite the initiation of anticoagulation at the earliest, large and mobile thrombi can embolise.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his/her consent for his/her images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published, and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Authors' contributions

KMK Reddy P, M Saitej Reddy, Praveen Nagula, Srinivas Ravi– Concept of Case series, drafting the manuscript, review of literature.

KMK Reddy P – management of cases, interpretation and analysis of cases, revised title of the manuscript, guarantor,

M.Saitej Reddy – admission and follow up of cases

Praveen Nagula – echocardiography, rewritten the manuscript

Ravi Srinivas – rewritten the manuscript, correspondence.

All the authors have gone through the revised manuscript and agreed for the submission to the journal after the proof reading.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Robinson AA, Jain A, Gentry M, McNamara RL. Left ventricular thrombi after STEMI in the primary PCI era: A systematic review and meta-analysis. Int J Cardiol 2016;221:554-9.  Back to cited text no. 1
    
2.
Gottdiener JS, Gay JA, VanVoorhees L, DiBianco R, Fletcher RD. Frequency and embolic potential of left ventricular thrombus in dilated cardiomyopathy: Assessment by 2-dimensional echocardiography. Am J Cardiol 1983;52:1281-5.  Back to cited text no. 2
    
3.
Habash F, Vallurupalli S. Challenges in management of left ventricular thrombus. Ther Adv Cardiovasc Dis 2017;11:203-13.  Back to cited text no. 3
    
4.
Srichai MB, Junor C, Rodrigue 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.  Back to cited text no. 4
    
5.
Nayak D, Aronow WS, Sukhija R, McClung JA, Monsen CE, Belkin RN. Comparison of frequency of left ventricular thrombi in patients with anterior wall versus non-anterior wall acute myocardial infarction treated with antithrombotic and antiplatelet therapy with or without coronary revascularization. Am J Cardiol 2004;93:1529-30.  Back to cited text no. 5
    
6.
Lai E, Alishetti S, Wong J, Delic L, Rosenblatt A, Egrie G. Right ventricular thrombus in transit: Raising the stakes in the management of pulmonary embolism. J Am Coll Cardiol 2019;73:2844.  Back to cited text no. 6
    
7.
Muthiah R. Left ventricular “horseshoe-thrombus” – A case report. Case Rep Clin Med 2016;5:140-6.  Back to cited text no. 7
    
8.
Vaitkus PT, Barnathan ES. Embolic potential, prevention and management of mural thrombus complicating anterior myocardial infarction: A meta-analysis. J Am Coll Cardiol 1993;22:1004-9.  Back to cited text no. 8
    
9.
Lee JM, Park JJ, Jung HW, Cho YS, Oh IY, Yoon CH, et al. Left ventricular thrombus and subsequent thromboembolism, comparison of anticoagulation, surgical removal, and antiplatelet agents. J Atheroscler Thromb 2013;20:73-93.  Back to cited text no. 9
    
10.
Cruz Rodriguez JB, Okajima K, Greenberg BH. Management of left ventricular thrombus: A narrative review. Ann Transl Med 2021;9:520.  Back to cited text no. 10
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6]
 
 
    Tables

  [Table 1]



 

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