Usefulness of contrast echocardiography for detection of left ventricular thrombus in a real-world population with acute anterior myocardial infarction

Abstract

Funding Acknowledgements Type of funding sources: None. Background/Introduction The treatment of ST-elevation myocardial infarction (STEMI) has considerably changed in recent years, with early, mainly transcatheter reperfusion therapy improving survival. However, left ventricular thrombus (LVT) is still reported as a relatively common complication especially in anterior STEMI. Two-dimensional transthoracic echocardiography (TTE) is the most commonly used diagnostic modality in this setting due to its wide availability and low cost but can lead to misdiagnoses. The use of ultrasound contrast agents has dramatically improved the visualization of cardiac chambers and thus detection of LVT. Purpose The purpose of this study was to assess the value of contrast echocardiography (CE) for the detection of apical LVT in a real-world population of patients with acute anterior myocardial infarction (MI) in the modern era. Methods The population of this prospective study consisted of consecutive patients presenting within a year with acute anterior MI in a tertiary hospital with capability of primary percutaneous coronary intervention (PCI). Patients with confirmed COVID-19 infection and/or current use of anticoagulant medication were excluded from the study. All patients underwent TTE without and with contrast within 7 days post-MI by an experienced cardiologist. CE was considered the reference standard. Results A total of 102 patients (mean age 61±13 years, 19% female) with anterior STEMI were prospectively recruited in our study. Ninety-eight patients underwent primary PCI, 3 patients underwent rescue PCI after unsuccessful thrombolysis, 1 patient underwent surgical revascularization. Two patients did not receive contrast agent (1 due to known hypersensitivity to contrast agent and 1 due to cardiogenic shock). Mean ejection fraction (EF) was 46% ± 10% in total population and was significantly lower in patients with LVT (42% ± 7% vs 47% ± 10%, p = 0.025). The incidence of confirmed LVT by CE was 28% (28/100) within 7 days post-MI. In total, 8 out of 28 LVT cases (28.5%) would have been missed using TTE without contrast within 7 days post-MI (sensitivity 71%, specificity 100%, positive predictive value 100% and negative predictive value 90%). Example of missed LVT on TTE without and with contrast (left and right panel respectively) is shown in Figure 1. Conclusions LVT is not uncommon after anterior STEMI in the modern era of primary PCI. LVT would have been missed in a significant proportion of patients with anterior STEMI if CE was not used, depriving these patients from the option of early anticoagulation treatment.