Long-Term Embolic Outcomes After Detection of Left Ventricular Thrombus by Late Gadolinium Enhancement Cardiovascular Magnetic Resonance Imaging

Abstract

Background: Late gadolinium enhancement (LGE) cardiovascular magnetic resonance (CMR) imaging is more sensitive than echocardiography for the detection of intracardiac thrombus because of its unique ability to identify thrombus based on tissue characteristics related to avascularity. The long-term prognostic significance of left ventricular (LV) thrombus detected by LGE CMR is unknown. Methods: We performed a matched cohort study of consecutive adult patients with LV thrombus detected by LGE CMR who were matched on the date of CMR, age, and LV ejection fraction to up to 3 patients without LV thrombus. We investigated the long-term incidence of a composite of embolic events: stroke, transient ischemic attack, or extracranial systemic arterial embolism. We also compared outcomes among patients with LV thrombus detected by LGE CMR stratified by whether the LV thrombus was also detected by echocardiography or not. Results: Of 157 LV thrombus patients, 155 were matched to 400 non-LV thrombus patients. During a median follow-up of 3.3 years, the cumulative incidence of embolism was significantly higher in LV thrombus patients compared with the matched non-LV thrombus patients ( P <0.001), with annualized rates of 3.7% and 0.8% for LV thrombus and matched non-LV thrombus patients, respectively. LV thrombus was the only independent predictor of the composite embolic end point (hazard ratio, 3.99 [95% CI, 1.54–10.35]; P =0.004). The cumulative incidence of embolism was not different in patients with LV thrombus that was also detected by echocardiography versus patients with LV thrombus not detected by echocardiography ( P =0.25). Conclusions: Despite contemporary antithrombotic treatment, LV thrombus detected by LGE CMR is associated with a 4-fold higher long-term incidence of embolism compared with matched non-LV thrombus patients. LV thrombus detected by LGE CMR but not by echocardiography is associated with a similar risk of embolism as that detected by both LGE CMR and echocardiography.

The Role of Multimodality Cardiovascular Imaging in Peripartum Cardiomyopathy

“…The use of contrast echocardiography may improve the detection of thrombosis through the identification of an LV filling defect (34). Nevertheless, CMR remains more sensitive than echocardiography for the detection of intracardiac thrombus, especially in the case of mural or smaller thrombi (35,36). Compared with late gadolinium enhancement (LGE) CMR as the reference standard, echocardiography has been shown to have a sensitivity of 24-37% when contrast is not used, with a higher sensitivity of <65% when contrast is used (36).…”

Clinical profile and midterm prognosis of left ventricular thrombus in heart failure

“…2 In matched analysis, the presence of LVT identified with magnetic resonance imaging (MRI) was associated with a four-fold higher long-term incidence of embolism. 3 Heart failure (HF) with reduced LV ejection fraction (LVEF), due to an ischaemic (ICM) or non-ischaemic dilated cardiomyopathy (DCM), is an emerging source of LVT. 4 In the setting of HF, several elements of Virchow's triad can be present; blood stasis is favoured by akinetic myocardial wall or severely decreased ventricular contraction, endothelium damage is favoured by necrosis or inflamed myocardium and increased shear stress, and hypercoagulable state can be increased by systemic inflammation, thrombophilia, and prothrombotic factor activation.…”

An Interesting Case of a Cold Left Arm

“…He possessed several risk factors for thrombotic or embolic disease even beyond his suspected atherosclerosis. For example, his old LV thrombus may have embolized at some point between its discovery and eventual resolution on echocardiogram [ 14 ], lodging itself in the subclavian artery. He had also developed an increasing burden of atrial arrhythmias since the cessation of anticoagulation for the LV thrombus.…”