Left ventricular thrombus diagnosed by point-of-care ultrasonography

Dear Editor,

A 63-year-old male presented to our Emergency Department for complaints of slurred speech and weakness of left upper extremity since 1-week. He has a prior history of hypertension, chronic obstructive lung disease, hyperthyroidism, anterior myocardial infarction, ischemic cerebrovascular accident, and recurrent transient ischemic attacks. A previously obtained coronary angiography demonstrated a totally occluded left anterior descending coronary artery at its proximal portion and stent implantation in a different session. On admission, his vital signs were normal, and electrocardiography evaluation demonstrated pathologic Q waves in the V1-V4 leads. Routine laboratory testing revealed normal electrolyte levels, renal, and liver functions. His activated partial thromboplastin time and prothrombin time with international normalized ratio were elevated (35.6 s “24-35 s” and 34.9 s “11-17 s” with 3.27 s “0.8-1.2 s,” respectively) due to his Coumadin therapy. Cranial computed tomography without contrast agent was ordered and depicted old infarct areas in the regions of left occipital lobe with the posterior part of the left parietal lobe and also findings of acute infarction in the left parietal lobe and periventricular areas. Apical four chamber view point-of-care cardiac ultrasonography (POCUS) performed by the emergency physician (EP) using a Mindray M7^® model ultrasound machine with a 3.6 mHz microconvex transducer (M7, Mindray Bio-medical Electronics Co., Shenzhen, China) revealed an enlarged left ventricle (LV), akinetic and aneurysmatic anterior wall, and a large, highly mobile pedunculated hypoechoic mass (1 cm × 2 cm) attached to the interventricular septum and LV apex junction, protruding the LV cavity [Figure 1]. Computerized tomography with contrast agent of the thorax revealed contrast filling defects in the same anatomical region of the LV cavity [Figure 2]. Cardiovascular surgery and neurology recommended an operational removal of the thrombus, but the patient refused the operation. He was discharged from the hospital with recommendations on anticoagulation and a follow-up plan. POCUS has evolved into a critical skill for the EP and has been utilized in a myriad of clinical situations.[1,2] The initial report on bedside echocardiography use by EPs was published in 1988 and initiated a period of intensive research and skills refinement that continues to the present day.[3] Some cardiac masses are suspected from the clinical presentation of the patient while others are incidental findings. Cardiac masses can be classified as a cardiac tumor, thrombus, vegetation, iatrogenic material, normal variant, or extracardiac structure. These masses can usually be differentiated by their size, shape, location, mobility, and attachment site, as well as by their clinical presentation. Accurate diagnosis is crucial because misinterpretation may lead to an incorrect management strategy, including an unnecessary surgical procedure.[4] Several echo features of LV thrombus must be evaluated, including the shape (mural or protruding) within the cavity, motion, which may be fixed or mobile, and size. A higher risk of embolization is attributable to larger thrombus size and/or thrombi that are mobile and protrude into the LV chamber. After diagnosis, echocardiographic follow-up is needed until thrombus eradication is obtained using anticoagulants.

Figure 1.

Apical four chamber view point-of-care cardiac ultrasonography showing an enlarged left ventricle, akinetic and aneurysmatic anterior wall, and a large, highly mobile pedunculated hypoechoic mass (1 cm × 2 cm) attached to the interventricular septum and left ventricle apex junction, protruding the left ventricle cavity

Figure 2.

Computerized tomography with contrast agent of the thorax revealed contrast filling defects in the same anatomical region of the left ventricle cavity