Vol. 145 No. 2526 (2015)
Thrombus formation in the left ventricle after large myocardial infarction – assessment with cardiac magnetic resonance imaging
- Daniel Sürder
- Valentin Gisler
- Roberto Corti
- Tiziano Moccetti
- Catherine Klersy
- Michel Zuber
- Stephan Windecker
- Aris Moschovitis
- Sebastian Kozerke
- Thomas Felix Lüscher
- Paul Erne
- Robert Manka
INTRODUCTION: Left ventricular thrombus (LVT) formation may worsen the post-infarct outcome as a result of thromboembolic events. It also complicates the use of modern antiplatelet regimens, which are not compatible with long-term oral anticoagulation. The knowledge of the incidence of LVT may therefore be of importance to guide antiplatelet and antithrombotic therapy after acute myocardial infarction (AMI).
METHODS: In 177 patients with large, mainly anterior AMI, standard cardiac magnetic resonance imaging (CMR) including cine and late gadolinium enhancement (LGE) imaging was performed shortly after AMI as per protocol. CMR images were analysed at an independent core laboratory blinded to the clinical data. Transthoracic echocardiography (TTE) was not mandatory for the trial, but was performed in 64% of the cases following standard of care. In a logistic model, 3 out of 61 parameters were used in a multivariable model to predict LVT.
RESULTS: LVT was detected by use of CMR in 6.2% (95% confidence interval [CI] 3.1%–10.8%). LGE sequences were best to detect LVT, which may be missed in cine sequences. We identified body mass index (odds ratio 1.18; p = 0.01), baseline platelet count (odds ratio 1.01, p = 0.01) and infarct size as assessed by use of CMR (odds ratio 1.03, p = 0.02) as best predictors for LVT. The agreement between TTE and CMR for the detection of LVT is substantial (kappa = 0.70).
DISCUSSION: In the current analysis, the incidence of LVT shortly after AMI is relatively low, even in a patient population at high risk. An optimal modality for LVT detection is LGE-CMR but TTE has an acceptable accuracy when LGE-CMR is not available.
- Nichols M, Townsend N, Scarborough P, Rayner M. Trends in age-specific coronary heart disease mortality in the European union over three decades: 1980–2009. Eur Heart J. 2013;34(39):3017–27.
- Fothergill RT, Watson LR, Virdi GK, Moore FP, Whitbread M. Survival of resuscitated cardiac arrest patients with st-elevation myocardial infarction (STEMI) conveyed directly to a heart attack centre by ambulance clinicians. Resuscitation. 2013, Sep 19.
- Stratton JR, Resnick AD. Increased embolic risk in patients with left ventricular thrombi. Circulation. 1987;75(5):1004–11.
- 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(4):1004–9.
- Asinger RW, Mikell FL, Elsperger J, Hodges M. Incidence of left-ventricular thrombosis after acute transmural myocardial infarction. Serial evaluation by two-dimensional echocardiography. N Engl J Med. 1981;305(6):297–302.
- Jugdutt BI, Sivaram CA. Prospective two-dimensional echocardiographic evaluation of left ventricular thrombus and embolism after acute myocardial infarction. J Am Coll Cardiol. 1989;13(3):554–64.
- Osherov AB, Borovik-Raz M, Aronson D, Agmon Y, Kapeliovich M, Kerner A, et al. Incidence of early left ventricular thrombus after acute anterior wall myocardial infarction in the primary coronary intervention era. Am Heart J. 2009;157(6):1074–80.
- Delewi R, Nijveldt R, Hirsch A, Marcu CB, Robbers L, Hassell ME, et al. Left ventricular thrombus formation after acute myocardial infarction as assessed by cardiovascular magnetic resonance imaging. Eur J Radiol. 2012;81(12):3900–4.
- Keating EC, Gross SA, Schlamowitz RA, Glassman J, Mazur JH, Pitt WA, Miller D. Mural thrombi in myocardial infarctions. Prospective evaluation by two-dimensional echocardiography. Am J Med. 1983;74(6):989–95.
- Weinreich DJ, Burke JF, Pauletto FJ. Left ventricular mural thrombi complicating acute myocardial infarction. Long-term follow-up with serial echocardiography. Ann Intern Med. 1984;100(6):789–94.
- Cregler LL. Antithrombotic therapy in left ventricular thrombosis and systemic embolism. Am Heart J. 1992;123(4 Pt 2):1110–4.
- Steg PG, James SK, Atar D, Badano LP, Blömstrom-Lundqvist C, Borger MA, et al. ESC guidelines for the management of acute myocardial infarction in patients presenting with st-segment elevation. Eur Heart J. 2012;33(20):2569–619.
- O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, et al. 2013 ACCF/AHA guideline for the management of st-elevation myocardial infarction: A report of the american college of cardiology foundation/american heart association task force on practice guidelines. Circulation. 2013;127(4):e362–425.
- Surder D, Schwitter J, Moccetti T, Astori G, Rufibach K, Plein S, et al. Cell-based therapy for myocardial repair in patients with acute myocardial infarction: Rationale and study design of the swiss multicenter intracoronary stem cells study in acute myocardial infarction (SWISS-AMI). Am Heart J. 2010;160(1):58–64.
- Sürder D, Manka R, Lo Cicero V, Moccetti T, Rufibach K, Soncin S, et al. Intracoronary injection of bone marrow derived mononuclear cells, early or late after acute myocardial infarction: Effects on global left ventricular function four months results of the SWISS-AMI trial. Circulation. 2013, Apr 17.
- Kim RJ, Wu E, Rafael A, Chen EL, Parker MA, Simonetti O, et al. The use of contrast-enhanced magnetic resonance imaging to identify reversible myocardial dysfunction. N Engl J Med. 2000;343(20):1445–53.
- Knuesel PR, Nanz D, Wyss C, Buechi M, Kaufmann PA, von Schulthess GK, et al. Characterization of dysfunctional myocardium by positron emission tomography and magnetic resonance: Relation to functional outcome after revascularization. Circulation. 2003;108(9):1095–100.
- Goetti R, Kozerke S, Donati OF, Sürder D, Stolzmann P, Kaufmann PA, et al. Acute, subacute, and chronic myocardial infarction: Quantitative comparison of 2D and 3D late gadolinium enhancement MR imaging. Radiology. 2011;259(3):704–11.
- Weinsaft JW, Kim HW, Shah DJ, Klem I, Crowley AL, Brosnan R, et al. Detection of left ventricular thrombus by delayed-enhancement cardiovascular magnetic resonance prevalence and markers in patients with systolic dysfunction. J Am Coll Cardiol. 2008;52(2):148–57.
- Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33(1):159–74
- Harrell FE Jr, Lee KL, Mark DB. Multivariable prognostic values: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med. 1996;15(4):361–87.
- Yalcinkaya E, Bugan B, Celik M, Yasar S, Demir M, Management of left ventricular thrombosis in patients with apical aneurysm. Swiss Med Wkly. 2013;143:w13866.
- Tang RB, Liu XH, Kalifa J, Li ZA, Dong JZ, Yang Y, et al. Body mass index and risk of left atrial thrombus in patients with atrial fibrillation. Am J Cardiol. 2009;104(12):1699–703.
- Solá E, Vayá A, Corella D, Santaolaria ML, España F, Estellés A, Hernández-Mijares A. Erythrocyte hyperaggregation in obesity: Determining factors and weight loss influence. Obesity (Silver Spring) 2007;15(8):2128–34.
- Berg AH, Scherer PE. Adipose tissue, inflammation, and cardiovascular disease. Circ Res. 2005;96(9):939–49.
- Bowles LK, Cooper JA, Howarth DJ, Miller GJ, MacCallum PK. Associations of haemostatic variables with body mass index: A community-based study. Blood Coagul Fibrinolysis. 2003;14(6):569–73.
- Darvall KA, Sam RC, Silverman SH, et al. Obesity and thrombosis. Eur J Vasc Endovasc Surg. 2007;33(2):223–33.
- Tefferi A. Polycythemia vera and essential thrombocythemia: 2013 update on diagnosis, risk-stratification, and management. Am J Hematol. 2013;88(6):507–16.
- Dewilde WJ, Oirbans T, Verheugt FW, et al. Use of clopidogrel with or without aspirin in patients taking oral anticoagulant therapy and undergoing percutaneous coronary intervention: An open-label, randomised, controlled trial. Lancet. 2013;381(9872):1107–15.
- Vonbach P, Reich R, Möll F, Krähenbühl S, Ballmer PE, Meier CR. Risk factor for gastrointestinal bleeding: a hospital-based case-control study. Swiss Med Wkly. 2007;137(49):705–10.
- Srichai MB, Junor C, Rodriguez 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(1):75–84.