Transatrial resection of a left ventricular thrombus after acute myocarditis

A mobile and pedunculated left ventricular thrombus developed after acute myocarditis in a 49-year-old woman. Surgical removal is recommended for cases such as this, especially when the ventricular thrombus is pedunculated or mobile. The thrombus was successfully removed by left atriotomy. There was no evidence of recurrent thrombus formation on the 50th day after surgery.     

Infection of left ventricular thrombus in a patient with silent myocardial infarction -- a unique complication

A 72-year-old male was admitted to hospital with exertionaldyspnoea of recent onset. Echocardiography showed a left ventriclewhich was severely hypokinetic on the anteroseptal and anteriorwall with an akinetic inferior wall and apex. A string of globularmasses was seen to be floating in the left ventricle, attachedto the septum near the apex. Coronary arteriography showed severetwo-vessel disease. Urgent surgery revealed degenerated thrombusin the left ventricle containing green pus. The infected thrombuswas attached to an area of septal infarction. The pus-filledthrombus was removed and by-pass grafting was effected. No infectiveorganism was identfled.     

扩张性心肌病形成左心室血栓的相关因素分析

目的:通过超声心动图观察,探讨扩张性心肌病左心室血栓形成的相关因素。方法:根据超声心动图检查有、无左心室血栓,83例扩张性心肌病患者被分为A组(左室血栓组)和B组(左室无血栓组)。结果:左房内径、左室收缩期末内径、EF值、二尖瓣中等返流及主动脉瓣返流量在两组之间有显著差异(P<0.05~<0.01),而左室舒张末内径、室壁厚度及年龄、性别则无差异。结论:左室收缩功能的降低,左房内径的增大对左室血栓的形成有重要促进作用。而二尖瓣及主动脉瓣的中等量返流对左室血栓的形成有一定的对抗作用。     

Abciximab and left ventricular thrombus formation in early period of acute myocardial infarction treated with successful primary stenting

Background Left ventricular (LV) thrombus related to acute myocardial infarction (AMI) has been rarely diagnosed since primary stenting has become the routine treatment. The salvage of myocardium at risk is considered as a reason for low frequency of this complication. The impact of glycoprotein IIb/IIIa inhibitors on LV thrombus formation remains unknown. This study investigated the relationship between abciximab treatment and presence of LV thrombus in the first few days after primary stenting. Methods and results A total of 3,078 patients with AMI, who underwent successful primary stenting, were retrospectively analyzed. There were 1,614 patients, who received abciximab and 1,414 treated without it. All patients received aspirin and clopidogrel. LV thrombus was diagnosed by two-dimensional echocardiography within 3–5 days after invasive treatment. This complication appeared equally frequently in both the abciximab and no-abciximab group (2.9% vs. 2.1%, respectively). According to results of multiple log-regression analysis, both groups did not differ in predictors of thrombus formation, such as infarct size and degree of LV dysfunction. Treatment with abciximab was not proved to be an independent predictor of LV thrombus absence. Conclusion Abciximab does not have a direct influence on LV thrombus formation in the early period of AMI.     

肥厚性心肌病合并左心室血栓的临床分析

目的 探讨合并左心室血栓的肥厚性心肌病(HCM)患者的临床特征和预后.方法 回顾性分析阜外心血管病医院2002年1月至2012年12月住院患者中经心脏磁共振证实有左心室血栓的HCM患者的临床资料及随访情况.结果 经磁共振证实有左心室血栓的HCM患者共6例(血栓组),左心室无血栓的HCM患者共284例(无血栓组),血栓组患者的心血管病家族史、室性心律失常和室壁瘤比例明显高于无血栓组(66.67％比21.48％,66.67％比5.63％,66.67％比0.35％,均为P＜0.05),左心房内径、左心室内径明显大于无血栓组[(47.67±6.28) mm比(39.88 ±7.37)mm,(55.83±7.13)mm比(45.25±6.55)mm,均为P＜0.05],而左心室射血分数和流出道梗阻比例明显低于无血栓组(41.50％±18.50％比67.14％±9.47％,0比47.54％,均为P＜0.05).有左心室血栓的患者接受华法林抗凝治疗,随访17～59个月,未发现血栓栓塞,2例复查血栓消失,3例死亡,l例进行了全心脏移植.结论 HCM合并左心室血栓见于有室壁瘤或左心室射血分数减低的患者,多合并室性心律失常,预后较差;还可发生栓塞事件,华法林可有效治疗左心室血栓.     

Left ventricular thrombus following acute myocardial infarction: A prospective serial echocardiographic study of 96 patients

In a prospective serial study of 96 patients with acute myocardialinfarction, two dimensional echocardiography identified leftventricular thrombus in 18 patients. The majority of thrombi(15) developed within the first 4 days after admission. In threepatients thrombi were identified for the first time 4 monthsafter the acute episode. All 18 patients had received therapeuticanticoagulants on admission and had large anterior wall infarctionscomplicated by serve pump failure and motion abnormalities echocardiographically.None of the patients had systemic embolisation during the studyperiod. Thus, left ventricular thrombus is a not uncommon thoughsilent complication of acute anterior wall infarction even whenpatients receive therapeutic anticoagulants.     

心肌梗死后室壁瘤并附壁血栓抗栓治疗随访

目的通过对心肌梗死后室壁瘤内附壁血栓形成的患者进行随访,评价抗血小板药物及抗凝药物对室壁瘤附壁血栓患者预后的影响。方法回顾性分析2002年3月-2009年2月,确诊为心肌梗死后室壁瘤内附壁血栓形成的66例内科治疗患者,其中单服阿斯匹林25例,阿斯匹林＋波立维（1年）27例,长期单纯华法林口服4例,阿斯匹林＋华法林6例,阿斯匹林＋华法林＋波立维（1年）3例。服用华法林者INR维持在1．8—3．0。出院后均继续规律服药,进行电话和门诊随访,并行Kaplan-Meier生存分析。结果66例中8例死亡：其中脑血栓、室间隔穿孔、脑出血及咯血各1例;猝死2例;心衰2例;存活58例中脑栓塞者2例;1例下肢血管栓塞及肺柃塞;1例下肢动脉栓塞,服用阿司匹林或华法林发生栓塞事件比率无差别,而联合抗栓治疗出血事件多,左心室射血分数〈35％事件发生率高。结论室壁瘤心功能差患者栓塞事件发生率高,阿斯匹林和华法林在预防心肌梗死后室壁瘤血栓栓塞脱落效果相似,但需更大样本和更长时间随访进一步证实。     

Thrombolytic therapy reduces the incidence of left ventricular thrombus after anterior myocardial infarction: Relationship to vessel patency and infarct size

BACKGROUND: Controversial evidence exists as to whether thrombolytic therapyreduces the incidence of left ventricular thrombus in acutemyocardial infarction and, if so, how this relates to successfulreperfusion. METHODS: Four hundred and eighteen consecutive patients underwent echocardiographyand coronary angiography within 3 weeks of an acute myocardialinfarction. A dyssynergic score was calculated by analysingregional wall motion in 18 left ventricular segments. The infarct-relatedartery was considered patent if TIMI grade 2 or 3 flow and lessthan 90% stenosis were present. Retrograde perfusion by Rentrop'sgrade 2 or 3 collaterals was considered significant. RESULTS: Large anterior myocardial infarctions were associated with thehighest prevalence (39%) of left ventricular thrombosis. Thrombuswas also very frequent if the left anterior descending coronaryartery was occluded and no collaterals to the infarct area wereseen (75%). Anticoagulant therapy reduced the prevalence ofleft ventricular thrombus, regardless of whether the infarct-relatedvessel was patent or not. Conversely, in patients undergoingthrombolysis the incidence of left ventricular thrombosis waslower when the left anterior descending coronary artery waspatent, and especially when an early creatine kinase peak, suggestiveof reperfusion, was recorded (7%). Finally, the presence ofleft ventricular thrombosis was inversely related to the asynergyscore. CONCLUSION: These observations suggest that the presence of left ventricularthrombus is related to the extent of myocardial damage. Thrombolytictherapy reduces thrombus probably by salvaging myocardium atrisk. (Eur Heart J 1996; 17: 421–428)     

急性心肌梗死合并左心室附壁血栓患者经皮冠状动脉介入术后的抗栓治疗

目的分析急性心肌梗死（AMI）并发左心室附壁血栓（LvT）行经皮冠脉介入治疗（PCI）患者的临床特征及抗栓治疗。方法收集煤炭总医院2005年8月至2012年2月确诊为急性心肌梗死并发左室附壁血栓并行PCI治疗的12例患者的临床资料,对其进行回顾性分析。结果广泛前壁心肌梗死、前壁心肌梗死9例（75％）,左室射血分数低于40％共7例（58％）,冠脉造影检查三支及以上血管病变7例（58％）。6例给予华法林、阿司匹林、氯吡格雷三联抗栓,2例给予西洛他唑、阿司匹林及氯吡格雷三联抗血小板治疗,随访期间血栓均消失。4例双联抗血小板治疗者l例发生脑梗死后加用华法林,3例患者血栓消失,1例血栓机化。12例患者均未出现严重出血现象。结论急性心肌梗死并发左心室附壁血栓并接受PCI治疗患者,充分衡量获益及出血风险,按照个体化原则给予抗栓治疗安全有效。     

Recurrent left ventricular mural thrombi in a patient with acute myocarditis

Summary A case of acute myocarditis with recurrent left ventricular mural thrombi in a 59-year-old man is reported. Two-dimensional echocardiogram demonstrated left ventricular mural thrombus with apical dyskinesis on the 2nd day after the onset of chest oppression. No hemoagglutination abnormalities were present. Anticoagulation treatment with heparin was initiated. A two-dimensional echocardiogram obtained on the 15th day showed that the left ventricular wall motion had become normal and that the thrombus had disappeared. However, on the 38th day, a new pedunculated free mobile thrombus was found in the apical part of the left ventricle despite the normal wall motion. By the 46th day, the new thrombus had disappeared.The present case suggests that mural thrombi can occur in the absence of left ventricular dyskinesis and dilatation. Anticoagulation therapy resolved the mural thrombi but could not prevent the recurrence at the apex. Thus, in acute myocarditis, a mural thrombus may appear as a result of the endocardial damage, even when blood stasis is absent.     

Determinants of left ventricular thrombus formation after primary percutaneous coronary intervention for anterior wall myocardial infarction

Previous studies have reported that left ventricular (LV) thrombus is a complication in 10–56% of ST-segment elevation acute anterior wall myocardial infarctions (AWMI). Data suggest that changes in acute myocardial infarction management such as early anticoagulation, thrombolysis, and most recently, primary percutaneous coronary intervention (PCI), may decrease thrombus occurrence. Early time to reperfusion has been shown to decrease mortality and improve LV function recovery. To determine if door-to-balloon time (DTBT) affects the incidence of LV thrombus, we retrospectively analyzed data on 43 consecutive patients who underwent successful PCI of a primary acute ST-segment elevation AWMI. Transthoracic echocardiography was performed for detecting LV thrombus and measuring LV ejection fraction (EF) within 5 days on all patients (average time: 2.17 days post event). Nineteen patients underwent PCI within 2 h of arrival to the Emergency Department (Group A, average 88 min) and 24 patients underwent PCI with DTBT of more than 2 h (Group B, average 193 min). Clinically significant LV thrombus was detected in 35% of all patients. The incidence of LV thrombus formation in Group A was not significantly different from that in Group B (42.1% vs. 29.0%, respectively; P = 0.52). The risk of LV thrombus was independent of in-hospital anticoagulation and medical management, peak enzyme levels, and LVEF but did relate to age (odds ratio = 1.96, 95% CI 1.03–3.73, P = 0.04 per decade). No embolic events in hospital were observed (average hospital stay 9.2 days). We conclude that the incidence of LV thrombus remains high despite PCI. Also, we find that DTBT in patients presenting with an ST-segment elevation AWMI does not affect the incidence of LV thrombus formation. Increased age, however, does appear to increase the risk of LV thrombus development.     

Large mobile pedunculated left ventricular thrombus: Identification by two-dimensional echocardiography

Two-dimensional echocardiography has permitted the noninvasive detection and determination of the course of the natural history of left ventricular thrombus. In this report we cite an illustrative case of the development of a large pedunculated mobile left ventricular thrombus in the setting of idiopathic congestive cardiomyopathy. A fatal cerebral embolization occurred despite full-dose intravenous anticoagulation before left ventricular thrombectomy could be performed. The presence of a large mobile pedunculated left ventricular thrombus in the setting of embolization and adequate anticoagulation may require surgical intervention.     

急性ST段抬高型心肌梗死左心室附壁血栓发生率及其危险因素调查

目的探讨急性广泛前壁或前壁ST段抬高型心肌梗死(STEMI)左心室附壁血栓(LVT)的发生率、危险因素及体循环栓塞发生率、治疗方案和预后。方法回顾性纳入2014年1月1日至2017年12月31日就诊于中国医学科学院阜外医院的急性广泛前壁或前壁STEMI患者1245例。收集1245例患者急诊就诊时、直接经皮冠状动脉介入治疗(PCI)术后当日、PCI术后连续3 d以及术后1周经胸超声心动图(TTE)检查结果,根据结果诊断LVT者39例,并以简单随机法抽取40例无LVT者作为对照组。对两组患者进行随访,主要临床终点为体循环栓塞事件。结果LVT组共39例(3.1%,39/1245),39例患者中广泛前壁STEMI 26例(66.7%)、前壁STEMI 13例(33.3%);非LVT组40例。两组随访12个月,LVT组体循环栓塞1例(2.6%),非LVT组体循环栓塞0例;LVEF<40%是发生LVT的独立危险因素(OR 11.696,95%CI 2.620~52.215,P=0.001)。结论LVT在急性广泛前壁或前壁STEMI患者中发病率为3.1%,体循环栓塞事件发生率为2.6%。LVEF<40%为LVT发生的独立危险因素。     

Acute myocarditis with thrombus near left ventricular outflow tract

A young woman presented with fulminant heart failure. Transthoracic echocardiography revealed severe left ventricular dysfunction with a mass adjacent to the basal anterior wall, near the left ventricular outflow tract (LVOT). The cause of the acute heart failure and mass was unclear. Transesophageal echocardiography, with contrast, and cardiac magnetic resonance imaging findings were consistent with thrombus near the LVOT. Cardiac biopsy suggested giant cell myocarditis. The patient was treated with anticoagulation, steroids, and heart failure medications with resolution of the thrombus. This case was remarkable for the location of thrombus at the base of the ventricle.     

Infection of cardiac mural thrombus associated with left ventricular aneurysm

Infection is a rare complication of cardiac mural thrombus andmay prove difficult to diagnose and treat. We describe a patientwith infected thrombus associated with a left ventricular aneurysm,involving Salmonella typhimurium. Cross-sectional echocardiographyproved helpful in establishing the diagnosis.     

Acute heart failure and near-syncope associated with giant left atrial ball thrombus occluding left ventricular inflow tract.

A 70-year-old female patient was admitted to our department with symptoms and signs of acute heart failure and near syncope. After hospitalization, both transthoracic echocardiography (TTE) and subsequent transesophageal echocardiography (TEE) demonstrated a giant (4.9 x 3.9 cm) mobile, irregular, bright left atrial mass consistent with left atrial ball thrombus (LABT).The mass was found to occlude the left ventricular inflow tract (LVIT) above the mitral orifice (supravalvular) in the presence of normal mitral leaflets. After emergent surgical excision, the pathology of the left atrial mass was found to be consistent with thrombus. The case presented here suffered acute diastolic heart failure and near-syncope due to obstruction of the LVIT above the mitral orifice by a giant LABT.     

The role of echocardiography in assessing the morphological response of left ventricular thrombus to anticoagulation

We present a patient with idiopathic dilated cardiomyopathy and a large left ventricular apical thrombus in which serial echocardiography over a 1-month period documented progressive enlargement of this mural thrombus. This case illustrates the dramatic progression of left ventricular thrombus size despite aggressive anticoagulation. In addition, the critical role of echocardiography in the diagnosis and follow-up of patients with left ventricular thrombus is emphasized.     

左心室质量及几何模式对左心室功能的影响

目的 探讨左心室质量(LVM)及几何模式对左心室功能的影响。方法 根据相对室壁厚度(RWT)>0.43和≤0.43将170例高血压患者分为向心性模式组和离心性模式组,分别作超声心动图检测。结果 向心性模式组的EF明显高于离心性模式组,而前者E、E/A明显低于后者。单变量及多变量回归分析均显示EF与LVM及RWT相关,E/A在单变量分析时与RWT呈非常显著负相关,但在多变量分析时被剔出。结论 LVM及几何模式的改变均对左心室收缩功能产生明显的损害,几何模式的变化可能对左心室舒张功能也会产生不利影响。     

Giant pedunculated thrombus with normal left ventricular systolic function mimicking myxoma

A 74-year-old woman with a history of essential thrombocythemia was admitted to the Coronary Care Unit because of atypical chest pain. The transthoracic echocardiogram showed normal left ventricular (LV) diameter and preserved regional and global systolic function. A pedunculated mobile mass measuring 25 mm × 14 mm was visualized in the LV cavity, attached to the midanterior wall. Because of the typical echocardiographic appearance, a myxoma was suspected. The patient evolved with left hemiparesis and negative T-waves in the electrocardiogram. Left ventriculotomy with excision of the ventricular mass was performed. Histopathological examination revealed an organized thrombus.