Embolic potential of left ventricular thrombus after myocardial infarction: A two-dimensional echocardiographic study of 119 patients

Abstract

Left ventricular thrombus complicating myocardial infarction was diagnosed by two-dimensional echocardiography in 119 patients. The infarct site was anterior in 98 patients and inferior in 11. Systemic embolism occurred in 26 patients (stroke in 18, lower limb embolism in 7 and mesenteric embolism in 1). A protruding configuration of the thrombus was more common in the patients with embolism than in those without (23 [88%] of 26 versus 17 [18%] of 93) (p less than 0.01). Free mobility of the thrombus was found in 15 (58%) of 26 and 3 (3%) of 93 cases, respectively (p less than 0.01). In predicting embolism, protruding thrombus configuration had a sensitivity of 88% and a specificity of 82%, and positive and negative predictive accuracy was 57 and 96%, respectively. For free mobility of the thrombus, sensitivity was 58%, specificity 97%, positive predictive accuracy 85% and negative predictive accuracy 89%. In the 46 patients whose echocardiogram was obtained during the hospital admission for the index infarct, repeat echocardiograms were obtained during oral anticoagulant therapy. Twelve of these 46 patients had embolism and 2 of the 12 died. In seven of these patients, full dose oral anticoagulant therapy had been given before embolism occurred and in five it was started after an embolic event. The thrombus decreased in size or disappeared in six patients; in four the thrombus showed no change, and in two of these four emboli recurred despite anticoagulation. It is concluded that two-dimensional echocardiography may help delineate the embolic potential of left ventricular thrombus complicating myocardial infarction and may be of value in weighing the benefits and disadvantages of oral anticoagulant therapy.

Comment on Guidelines on oral anticoagulation with warfarin – 4th edition. Response to Gosai & Muthusamy

“…Regression in size of the thrombus was seen in those treated with anticoagulation. Low levels of symptomatic systemic embolization were seen in this and other studies that demonstrated similar incidence (Visser et al, 1985;Johannessen et al, 1987;Keren et al, 1990). In a review, Cregler (1992) advocated 3 months of warfarin therapy for those with large anterior myocardial infarction or post-infarct heart failure.…”

Comment on Guidelines on oral anticoagulation with warfarin – 4th edition

“…Regression in size of the thrombus was seen in those treated with anticoagulation. Low levels of symptomatic systemic embolization were seen in this and other studies that demonstrated similar incidence (Visser et al, 1985;Johannessen et al, 1987;Keren et al, 1990). In a review, Cregler (1992) advocated 3 months of warfarin therapy for those with large anterior myocardial infarction or post-infarct heart failure.…”

A Rare Case Report of A Pulseless Male Patient With Sequale of Takayasu’s Arteritis.

“…Left ventricular thrombi (a frequent complication of transmural acute myocardial infarction, likely to be the case in our patient) 7,8 , are second to atrial thrombi from atrial fibrillation as a cause of cardiogenic embolization. These are easily detectable by two-dimensional echocardiography, although false-positive studies exist 9 .Protruding configuration and free mobility of the thrombus and the presence of adjacent hypokinesia indicate a high embolization potential 10,11 . The presence of a potential embolic source does not, by itself, justify The cause of coronary artery disease in a young patient with a pulseless right arm was further evaluated and was to our surprise a rare entity Takayasu's arteritis.…”