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Echocardiographic Algorithm for Post-Myocardial Infarction LV Thrombus: A Gatekeeper for Thrombus Evaluation by Delayed Enhancement CMR.

Publication ,  Journal Article
Weinsaft, JW; Kim, J; Medicherla, CB; Ma, CL; Codella, NCF; Kukar, N; Alaref, S; Kim, RJ; Devereux, RB
Published in: JACC Cardiovasc Imaging
May 2016

OBJECTIVES: The goal of this study was to determine the prevalence of post-myocardial infarction (MI) left ventricular (LV) thrombus in the current era and to develop an effective algorithm (predicated on echocardiography [echo]) to discern patients warranting further testing for thrombus via delayed enhancement (DE) cardiac magnetic resonance (CMR). BACKGROUND: LV thrombus affects post-MI management. DE-CMR provides thrombus tissue characterization and is a well-validated but an impractical screening modality for all patients after an MI. METHODS: A same-day echo and CMR were performed according to a tailored protocol, which entailed uniform echo contrast (irrespective of image quality) and dedicated DE-CMR for thrombus tissue characterization. RESULTS: A total of 201 patients were studied; 8% had thrombus according to DE-CMR. All thrombi were apically located; 94% of thrombi occurred in the context of a left anterior descending (LAD) infarct-related artery. Although patients with thrombus had more prolonged chest pain and larger MI (p ≤ 0.01), only 18% had aneurysm on echo (cine-CMR 24%). Noncontrast (35%) and contrast (64%) echo yielded limited sensitivity for thrombus on DE-CMR. Thrombus was associated with stepwise increments in basal → apical contractile dysfunction on echo and quantitative cine-CMR; the echo-measured apical wall motion score was higher among patients with thrombus (p < 0.001) and paralleled cine-CMR decrements in apical ejection fraction and peak ejection rates (both p < 0.005). Thrombus-associated decrements in apical contractile dysfunction were significant even among patients with LAD infarction (p < 0.05). The echo-based apical wall motion score improved overall performance (area under the curve 0.89 ± 0.44) for thrombus compared with ejection fraction (area under the curve 0.80 ± 0.61; p = 0.01). Apical wall motion partitions would have enabled all patients with LV thrombus to be appropriately referred for DE-CMR testing (100% sensitivity and negative predictive value), while avoiding further testing in more than one-half (56% to 63%) of patients. CONCLUSIONS: LV thrombus remains common, especially after LAD MI, and can occur even in the absence of aneurysm. Although DE-CMR yielded improved overall thrombus detection, apical wall motion on a noncontrast echocardiogram can be an effective stratification tool to identify patients in whom DE-CMR thrombus assessment is most warranted. (Diagnostic Utility of Contrast Echocardiography for Detection of LV Thrombi Post ST Elevation Myocardial Infarction; NCT00539045).

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Published In

JACC Cardiovasc Imaging

DOI

EISSN

1876-7591

Publication Date

May 2016

Volume

9

Issue

5

Start / End Page

505 / 515

Location

United States

Related Subject Headings

  • Ventricular Function, Left
  • Unnecessary Procedures
  • Thrombosis
  • Stroke Volume
  • Reproducibility of Results
  • Referral and Consultation
  • Prospective Studies
  • Prognosis
  • Prevalence
  • Predictive Value of Tests
 

Citation

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Weinsaft, J. W., Kim, J., Medicherla, C. B., Ma, C. L., Codella, N. C. F., Kukar, N., … Devereux, R. B. (2016). Echocardiographic Algorithm for Post-Myocardial Infarction LV Thrombus: A Gatekeeper for Thrombus Evaluation by Delayed Enhancement CMR. JACC Cardiovasc Imaging, 9(5), 505–515. https://doi.org/10.1016/j.jcmg.2015.06.017
Weinsaft, Jonathan W., Jiwon Kim, Chaitanya B. Medicherla, Claudia L. Ma, Noel C. F. Codella, Nina Kukar, Subhi Alaref, Raymond J. Kim, and Richard B. Devereux. “Echocardiographic Algorithm for Post-Myocardial Infarction LV Thrombus: A Gatekeeper for Thrombus Evaluation by Delayed Enhancement CMR.JACC Cardiovasc Imaging 9, no. 5 (May 2016): 505–15. https://doi.org/10.1016/j.jcmg.2015.06.017.
Weinsaft JW, Kim J, Medicherla CB, Ma CL, Codella NCF, Kukar N, et al. Echocardiographic Algorithm for Post-Myocardial Infarction LV Thrombus: A Gatekeeper for Thrombus Evaluation by Delayed Enhancement CMR. JACC Cardiovasc Imaging. 2016 May;9(5):505–15.
Weinsaft, Jonathan W., et al. “Echocardiographic Algorithm for Post-Myocardial Infarction LV Thrombus: A Gatekeeper for Thrombus Evaluation by Delayed Enhancement CMR.JACC Cardiovasc Imaging, vol. 9, no. 5, May 2016, pp. 505–15. Pubmed, doi:10.1016/j.jcmg.2015.06.017.
Weinsaft JW, Kim J, Medicherla CB, Ma CL, Codella NCF, Kukar N, Alaref S, Kim RJ, Devereux RB. Echocardiographic Algorithm for Post-Myocardial Infarction LV Thrombus: A Gatekeeper for Thrombus Evaluation by Delayed Enhancement CMR. JACC Cardiovasc Imaging. 2016 May;9(5):505–515.
Journal cover image

Published In

JACC Cardiovasc Imaging

DOI

EISSN

1876-7591

Publication Date

May 2016

Volume

9

Issue

5

Start / End Page

505 / 515

Location

United States

Related Subject Headings

  • Ventricular Function, Left
  • Unnecessary Procedures
  • Thrombosis
  • Stroke Volume
  • Reproducibility of Results
  • Referral and Consultation
  • Prospective Studies
  • Prognosis
  • Prevalence
  • Predictive Value of Tests