title: Echocardiographic Algorithm for Post-Myocardial Infarction LV Thrombus: A Gatekeeper for Thrombus Evaluation by Delayed Enhancement CMR.
abstract: 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).
  
  
  
  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.
  
  
  
  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.
  
  
  
  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.
  
  
  
  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).
authors.affiliation: Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Radiology, Weill Cornell Medical College, New York, New York. Electronic address: jww2001@med.cornell.edu.
authors.forename: Jonathan W
authors.initials: JW
authors.lastname: Weinsaft
authors.affiliation: Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York; Department of Radiology, Weill Cornell Medical College, New York, New York.
authors.forename: Jiwon
authors.initials: J
authors.lastname: Kim
authors.affiliation: Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York.
authors.forename: Chaitanya B
authors.initials: CB
authors.lastname: Medicherla
authors.affiliation: Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York.
authors.forename: Claudia L
authors.initials: CL
authors.lastname: Ma
authors.affiliation: IBM T.J. Watson Research Center, Yorktown Heights, New York.
authors.forename: Noel C F
authors.initials: NC
authors.lastname: Codella
authors.affiliation: Memorial Sloan Kettering Cancer Center, New York, New York.
authors.forename: Nina
authors.initials: N
authors.lastname: Kukar
authors.affiliation: Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York.
authors.forename: Subhi
authors.initials: S
authors.lastname: Alaref
authors.affiliation: Duke Cardiovascular Magnetic Resonance Center, Durham, North Carolina.
authors.forename: Raymond J
authors.initials: RJ
authors.lastname: Kim
authors.affiliation: Greenberg Cardiology Division, Department of Medicine, Weill Cornell Medical College, New York, New York.
authors.forename: Richard B
authors.initials: RB
authors.lastname: Devereux
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D003287:Contrast Media / Q000008:administration & dosage; D004452:Echocardiography / Q000379:methods*; D005260:Female; D006322:Heart Aneurysm / Q000000981:diagnostic imaging / Q000453:epidemiology; D006801:Humans; D007090:Image Interpretation, Computer-Assisted / Q000379:methods*; D019028:Magnetic Resonance Imaging, Cine; D008297:Male; D008875:Middle Aged; D009203:Myocardial Infarction / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000503:physiopathology; D011237:Predictive Value of Tests; D015995:Prevalence; D011379:Prognosis; D011446:Prospective Studies; D012017:Referral and Consultation; D015203:Reproducibility of Results; D013318:Stroke Volume; D013927:Thrombosis / Q000000981:diagnostic imaging* / Q000453:epidemiology / Q000503:physiopathology; D019564:Unnecessary Procedures; D016277:Ventricular Function, Left
chemical_list: D003287:Contrast Media
keywords: cardiovascular magnetic resonance; echocardiography; left ventricular thrombus